title: Eroded Versus Ruptured Plaques at the Culprit Site of STEMI: In Vivo Pathophysiological Features and Response to Primary PCI.
abstract: OBJECTIVE
  The aim of this study was to evaluate the pathophysiological features and response to primary percutaneous coronary intervention (PCI) of nonruptured/eroded plaque versus ruptured plaque as a cause of ST-segment elevation myocardial infarction (STEMI).
  
  
  BACKGROUND
  Autopsy series identified nonruptured/eroded plaque and ruptured plaque as the principal pathological substrates underlying coronary thrombosis in STEMI. The real incidence of different plaque morphologies, associated biological factors, superimposed thrombus, and their interaction with primary PCI remain largely unknown.
  
  
  METHODS
  In a prospective study, 140 patients with STEMI underwent optical coherence tomography of the infarct-related artery (IRA) before PCI, after everolimus-eluting stent implantation and at 9-month follow-up. Histopathology and immunohistochemistry of thrombus aspirates and serum biomarkers were assessed at baseline.
  
  
  RESULTS
  Culprit plaque morphology was adjudicated in 97 patients: 32 plaques (33.0%) with an intact fibrous cap (IFC), 63 (64.9%) plaques with a ruptured fibrous cap (RFC), and 2 (2.1%) spontaneous dissections. Patients with an IFC and RFC had similar clinical characteristics, and serum inflammatory and platelets biomarkers. An IFC presented more frequently with a patent IRA (56.2% vs. 34.9%; p = 0.047), and had fewer lipid areas (lipid-rich areas: 75.0% vs. 100.0%; p < 0.001) and less residual thrombus before stenting (white thrombus: 0.41 mm(3) vs. 1.52 mm(3); p = 0.001; red thrombus: 0 mm(3) vs. 0.29 mm(3); p = 0.001) with a lower peak of creatine kinase-myocardial band (66.6 IU/l vs. 149.8 IU/l; p = 0.025). At the 9-month optical coherence tomography, IFC and RFC had similar high rates of stent strut coverage (92.5% vs. 91.2%; p = 0.15) and similar percentage of volume obstruction (12.6% vs. 10.2%; p = 0.27). No significant differences in clinical outcomes were observed up to 2 years.
  
  
  CONCLUSIONS
  In the present study, an IFC was observed at the culprit lesion site of one-third of STEMIs. IFC, compared with RFC, was associated with higher rates of patent IRA at first angiography, fewer lipid areas, and residual endoluminal thrombus. However, no difference in vascular response to everolimus-eluting stent was observed. (Optical Coherence Tomography Assessment of Gender Diversity in Primary Angioplasty [OCTAVIA]; NCT01377207).
authors.affiliation: Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy. Electronic address: francescosaia@hotmail.com.
authors.forename: Francesco
authors.initials: F
authors.lastname: Saia
authors.affiliation: Interventional Cardiology Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy.
authors.forename: Kenichi
authors.initials: K
authors.lastname: Komukai
authors.affiliation: Ferrarotto Hospital, University of Catania, Catania, Italy.
authors.forename: Davide
authors.initials: D
authors.lastname: Capodanno
authors.affiliation: Interventional Cardiology Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy.
authors.forename: Vasile
authors.initials: V
authors.lastname: Sirbu
authors.affiliation: Interventional Cardiology Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Musumeci
authors.affiliation: Cardiology Department, Ospedale San Giovanni Bosco, Torino, Italy.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Boccuzzi
authors.affiliation: Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Padua, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Tarantini
authors.affiliation: Department of Cardiology, Policlinico Le Scotte, Siena, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Fineschi
authors.affiliation: Cardiology Department, Ospedale Civile, Asti, Italy.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Tumminello
authors.affiliation: Interventional Cardiology Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Bernelli
authors.affiliation: Institute of Cardiology, Catholic University of the Sacred Heart, Roma, Italy.
authors.forename: Giampaolo
authors.initials: G
authors.lastname: Niccoli
authors.affiliation: Interventional Cardiology Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy.
authors.forename: Micol
authors.initials: M
authors.lastname: Coccato
authors.affiliation: Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.
authors.forename: Barbara
authors.initials: B
authors.lastname: Bordoni
authors.affiliation: Case Western Reserve University, Cleveland, Ohio.
authors.forename: Hiram
authors.initials: H
authors.lastname: Bezerra
authors.affiliation: Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Biondi-Zoccai
authors.affiliation: CV Path Institute, Gaithersburg, Maryland.
authors.forename: Renu
authors.initials: R
authors.lastname: Virmani
authors.affiliation: Interventional Cardiology Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy.
authors.forename: Giulio
authors.initials: G
authors.lastname: Guagliumi
mesh_terms: D000368:Aged; D015415:Biomarkers / Q000097:blood; D002317:Cardiovascular Agents / Q000008:administration & dosage; D003324:Coronary Artery Disease / Q000097:blood / Q000150:complications / Q000473:pathology / Q000628:therapy*; D003328:Coronary Thrombosis / Q000097:blood / Q000150:complications / Q000473:pathology / Q000628:therapy*; D003331:Coronary Vessels / Q000187:drug effects / Q000378:metabolism / Q000473:pathology*; D054855:Drug-Eluting Stents; D000068338:Everolimus / Q000008:administration & dosage; D005260:Female; D005355:Fibrosis; D006801:Humans; D007150:Immunohistochemistry; D018836:Inflammation Mediators / Q000097:blood; D007558:Italy; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000209:etiology / Q000473:pathology / Q000628:therapy*; D062645:Percutaneous Coronary Intervention / Q000295:instrumentation; D058226:Plaque, Atherosclerotic; D011446:Prospective Studies; D011474:Prosthesis Design; D012422:Rupture, Spontaneous; D017131:Thrombectomy; D013997:Time Factors; D041623:Tomography, Optical Coherence; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D002317:Cardiovascular Agents; D018836:Inflammation Mediators; D000068338:Everolimus
keywords: ST-segment elevation myocardial infarction; culprit plaque; optical coherence tomography; percutaneous coronary intervention; plaque erosion