Impact of Longitudinal Lesion Geometry on Location of Plaque Rupture and Clinical Presentations.
This study sought to investigate the impact of longitudinal lesion geometry on the location of plaque rupture and clinical presentation and its mechanism.



The relationships among lesion geometry, external hemodynamic forces acting on the plaque, location of plaque rupture, and clinical presentation have not been comprehensively investigated.



This study enrolled 125 patients with plaque rupture documented by intravascular ultrasound. Longitudinal locations of plaque rupture were identified and categorized by intravascular ultrasound. Patients' clinical presentations and TIMI (Thrombolysis In Myocardial Infarction) flow grade in an initial angiogram were compared according to the location of plaque rupture. Longitudinal lesion asymmetry was quantitatively assessed by the luminal radius change over the segment length (radius gradient [RG]). Lesions with a steeper radius change in the upstream segment compared with the downstream segment (RGupstream> RGdownstream) were defined as upstream-dominant lesions.



On the basis of the site of maximum rupture aperture, 56.0%, 16.0%, and 28.0% of the patients had upstream, minimal lumen area, and downstream rupture, respectively. Patients with upstream rupture more frequently presented with ST-segment elevation myocardial infarction (45.7%, 40.0%, 22.9%; p = 0.030) and with TIMI flow grade <3 (32.9%, 20.0%, 17.1%; p = 0.042). According to the ratio of upstream and downstream RG, 69.5% of lesions were classified as upstream-dominant lesions, and 30.5% were classified as downstream-dominant lesions. Among the 66 upstream-dominant lesions, 65 cases (98.5%) had upstream rupture, and the RG ratio (RGupstream/RGdownstream) was an independent predictor of upstream rupture (odds ratio: 1.481; 95% confidence interval: 1.035 to 2.120; p = 0.032). Upstream-dominant lesions more frequently manifested with ST-segment elevation myocardial infarction than did downstream-dominant lesions (48.5% vs. 24.1%; p = 0.026).



Both clinical presentation and degree of flow limitation were associated with the location of plaque rupture. Longitudinal lesion asymmetry assessed by RG, which can affect regional distribution of hemodynamic stress, was associated with the location of rupture and with clinical presentation.
Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
Joo Myung
JM
Lee
HeartFlow, Inc., Redwood City, California; Department of Surgery, Stanford University Medical Center, Stanford, California.
Gilwoo
G
Choi
Department of Medicine, Seoul National University Hospital, Seoul, South Korea.
Doyeon
D
Hwang
Department of Medicine, Seoul National University Hospital, Seoul, South Korea.
Jonghanne
J
Park
HeartFlow, Inc., Redwood City, California.
Hyun Jin
HJ
Kim
Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea.
Joon-Hyung
JH
Doh
Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea.
Chang-Wook
CW
Nam
Department of Internal Medicine and Emergency Medical Center, Seoul National University Hospital, Seoul, South Korea; Institute of Aging, Seoul National University, Seoul, South Korea.
Sang-Hoon
SH
Na
Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea. Electronic address: ses@uuh.ulsan.kr.
Eun-Seok
ES
Shin
HeartFlow, Inc., Redwood City, California; Department of Bioengineering, Stanford University, Stanford, California.
Charles A
CA
Taylor
Department of Medicine, Seoul National University Hospital, Seoul, South Korea; Institute of Aging, Seoul National University, Seoul, South Korea. Electronic address: bkkoo@snu.ac.kr.
Bon-Kwon
BK
Koo
D000368:Aged; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000503:physiopathology; D003326:Coronary Circulation; D003331:Coronary Vessels / Q000000981:diagnostic imaging* / Q000503:physiopathology; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008955:Models, Cardiovascular; D015999:Multivariate Analysis; D016017:Odds Ratio; D058226:Plaque, Atherosclerotic; D011237:Predictive Value of Tests; D012307:Risk Factors; D012422:Rupture, Spontaneous; D018084:Ultrasonography, Interventional
computational fluid dynamics; coronary plaque; intravascular ultrasound; myocardial infarction; plaque rupture