title: Relation of ruptured plaque culprit lesion phenotype and outcomes in patients with ST elevation acute myocardial infarction.
abstract: We used virtual histology intravascular ultrasound (VH-IVUS) to assess culprit plaque rupture in 172 patients with ST-segment elevation acute myocardial infarction. VH-IVUS-defined thin-capped fibroatheroma (VH-TCFA) had necrotic core (NC) > 10% of plaque area, plaque burden > 40%, and NC in contact with the lumen for ≥ 3 image slices. Ruptured plaques were present in 72 patients, 61% of which were located in the proximal 30 mm of a coronary artery. Thirty-five were classified as VH-TCFA and 37 as non-VH-TCFA. Vessel size, lesion length, plaque burden, minimal lumen area, and frequency of positive remodeling were similar in VH-TCFA and non-VH-TCFA. However, the NC areas within the rupture sites of VH-TCFAs were larger compared to non-VH-TCFAs (p = 0.002), while fibrofatty plaque areas were larger in non-VH-TCFAs (p < 0.0001). Ruptured plaque cavity size was correlated with distal reference lumen area (r = 0.521, p = 0.00002), minimum lumen area (r = 0.595, p < 0.0001), and plaque area (r = 0.267, p = 0.033). Sensitivity and specificity curve analysis showed that a minimum lumen area of 3.5 mm2, a distal reference lumen area of 7.5 mm2, and a maximum NC area of 35% best predicted plaque rupture. Although VH-TCFA (35 of 72) was the most frequent phenotype of plaque rupture in ST-segment elevation myocardial infarction, plaque rupture also occurred in non-VH-TCFA: pathologic intimal thickening (8 of 72), thick-capped fibroatheroma (1 of 72), and fibrotic (14 of 72) and fibrocalcified (14 of 72) plaque. In conclusion, not all culprit plaque ruptures in patients with ST-segment elevation myocardial infarction occur as a result of TCFA rupture; a prominent fibrofatty plaque, especially in a proximal vessel, may be another form of vulnerable plaque. Further study should identify additional factors causing plaque rupture.
authors.affiliation: Chung-Ang University Hospital, Seoul, Korea. swivus@gmail.com
authors.forename: Sang Wook
authors.initials: SW
authors.lastname: Kim
authors.forename: Young Joon
authors.initials: YJ
authors.lastname: Hong
authors.forename: Gary S
authors.initials: GS
authors.lastname: Mintz
authors.forename: Sung Yun
authors.initials: SY
authors.lastname: Lee
authors.forename: Jun Hyung
authors.initials: JH
authors.lastname: Doh
authors.forename: Seong Hoon
authors.initials: SH
authors.lastname: Lim
authors.forename: Hyun Jae
authors.initials: HJ
authors.lastname: Kang
authors.forename: Seung Woon
authors.initials: SW
authors.lastname: Rha
authors.forename: Jung Sun
authors.initials: JS
authors.lastname: Kim
authors.forename: Wang-Soo
authors.initials: WS
authors.lastname: Lee
authors.forename: Seong Jin
authors.initials: SJ
authors.lastname: Oh
authors.forename: Sahng
authors.initials: S
authors.lastname: Lee
authors.forename: Joo Yong
authors.initials: JY
authors.lastname: Hahn
authors.forename: Jin Bae
authors.initials: JB
authors.lastname: Lee
authors.forename: Jang Ho
authors.initials: JH
authors.lastname: Bae
authors.forename: Seung Ho
authors.initials: SH
authors.lastname: Hur
authors.forename: Seung Hwan
authors.initials: SH
authors.lastname: Han
authors.forename: Myung Ho
authors.initials: MH
authors.lastname: Jeong
authors.forename: Young Jo
authors.initials: YJ
authors.lastname: Kim
mesh_terms: D015906:Angioplasty, Balloon, Coronary; D017023:Coronary Angiography; D003331:Coronary Vessels / Q000000981:diagnostic imaging / Q000473:pathology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D010641:Phenotype; D058226:Plaque, Atherosclerotic / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology; D011379:Prognosis; D011446:Prospective Studies; D056910:Republic of Korea / Q000453:epidemiology; D012422:Rupture, Spontaneous; D015996:Survival Rate / Q000639:trends; D018084:Ultrasonography, Interventional