title: How do we prevent the vulnerable atherosclerotic plaque from rupturing? Insights from in vivo assessments of plaque, vascular remodeling, and local endothelial shear stress.
abstract: Coronary atherosclerosis progresses both as slow, gradual enlargement of focal plaque and also as a more dynamic process with periodic abrupt changes in plaque geometry, size, and morphology. Systemic vasculoprotective therapies such as statins, angiotensin-converting enzyme inhibitors, and antiplatelet agents are the cornerstone of prevention of plaque rupture and new adverse clinical outcomes, but such systemic therapies are insufficient to prevent the majority of new cardiac events. Invasive imaging methods have been able to identify both the anatomic features of high-risk plaque and the ongoing pathobiological stimuli responsible for progressive plaque inflammation and instability and may provide sufficient information to formulate preventive local mechanical strategies (eg, preemptive percutaneous coronary interventions) to avert cardiac events. Local endothelial shear stress (ESS) triggers vascular phenomena that synergistically exacerbate atherosclerosis toward an unstable phenotype. Specifically, low ESS augments lipid uptake and catabolism, induces plaque inflammation and oxidation, downregulates the production, upregulates the degradation of extracellular matrix, and increases cellular apoptosis ultimately leading to thin-cap fibroatheromas and/or endothelial erosions. Increases in blood thrombogenicity that result from either high or low ESS also contribute to plaque destabilization. An understanding of the actively evolving vascular phenomena, as well as the development of in vivo imaging methodologies to identify the presence and severity of the different processes, may enable early identification of a coronary plaque destined to acquire a high-risk state and allow for highly selective, focal preventive interventions to avert the adverse natural history of that particular plaque. In this review, we focus on the role of ESS in the pathobiologic processes responsible for plaque destabilization, leading either to accelerated plaque growth or to acute coronary events, and emphasize the potential to utilize in vivo risk stratification of individual coronary plaques to optimize prevention strategies to preclude new cardiac events.
authors.affiliation: The Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Ioannis
authors.initials: I
authors.lastname: Andreou
authors.affiliation: The Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Antonios P
authors.initials: AP
authors.lastname: Antoniadis
authors.affiliation: The Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Koki
authors.initials: K
authors.lastname: Shishido
authors.affiliation: The Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Michail I
authors.initials: MI
authors.lastname: Papafaklis
authors.affiliation: The Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Konstantinos C
authors.initials: KC
authors.lastname: Koskinas
authors.affiliation: The Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Yiannis S
authors.initials: YS
authors.lastname: Chatzizisis
authors.affiliation: The Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Ahmet U
authors.initials: AU
authors.lastname: Coskun
authors.affiliation: The Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Elazer R
authors.initials: ER
authors.lastname: Edelman
authors.affiliation: The Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Charles L
authors.initials: CL
authors.lastname: Feldman
authors.affiliation: The Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA pstone@partners.org.
authors.forename: Peter H
authors.initials: PH
authors.lastname: Stone
mesh_terms: D004730:Endothelium, Vascular / Q000503:physiopathology*; D005109:Extracellular Matrix / Q000378:metabolism; D006801:Humans; D008077:Lipoproteins, LDL / Q000378:metabolism; D018384:Oxidative Stress; D058226:Plaque, Atherosclerotic / Q000175:diagnosis / Q000188:drug therapy* / Q000473:pathology / Q000503:physiopathology; D000067759:Receptor for Advanced Glycation End Products / Q000502:physiology; D013314:Stress, Mechanical; D066253:Vascular Remodeling
chemical_list: D008077:Lipoproteins, LDL; D000067759:Receptor for Advanced Glycation End Products
keywords: atherosclerosis; shear stress; vulnerable plaque