急性冠状动脉综合征患者的罪犯斑块愈合。

Healed Culprit Plaques in Patients With Acute Coronary Syndromes.

机构信息

Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli-IRCCS, Rome, Italy.

出版信息

J Am Coll Cardiol. 2019 May 14;73(18):2253-2263. doi: 10.1016/j.jacc.2018.10.093.

DOI:10.1016/j.jacc.2018.10.093

PMID:31072568

Abstract

BACKGROUND

Healed plaques, morphologically characterized by a layered phenotype, are frequently found in subjects with sudden cardiac death. However, in vivo data are lacking.

OBJECTIVES

The purpose of this study was to determine the prevalence, morphological characteristics, and clinical significance of healed culprit plaques in patients with acute coronary syndromes (ACS) using optical coherence tomography (OCT).

METHODS

A total of 376 ACS patients (252 ST-segment elevation myocardial infarction [MI] and 124 non-ST-segment elevation acute coronary syndrome) who had undergone pre-intervention OCT imaging of the culprit lesion were enrolled. Patients were stratified according to the presence of layered phenotype, defined as layers of different optical density at OCT. Clinical and laboratory data, OCT characteristics, and 1-year outcome were compared between the 2 groups.

RESULTS

Among 376 patients, 108 (28.7%) healed plaques were identified. Hyperlipidemia, diabetes, and history of MI were more frequent in patients with healed plaques (44.4% vs. 33.2%; p = 0.041; 35.2% vs. 23.5%; p = 0.021; and 15.7% vs. 6.3%; p = 0.009, respectively). High-sensitivity C-reactive protein was significantly higher in patients with healed plaques (median 4.98 mg/l [interquartile range: 1.00 to 11.32 mg/l] vs. 3.00 mg/l [interquartile range: 0.30 to 10.15 mg/l]; p = 0.029). Plaque rupture (64.8% vs. 53.0%; p = 0.039), thin cap fibroatheroma (56.5% vs. 42.5%; p = 0.016), and macrophage accumulation (81.1% vs. 63.4%; p = 0.001) were common in the layered group. OCT also revealed greater area stenosis in plaques with layered phenotype (79.2 ± 9.5% vs. 74.3 ± 14.3%; p = 0.001). The incidence of major adverse cardiovascular events was similar between the 2 groups, except that the all-cause rehospitalization rate was higher among healed plaques (32.7% vs. 16.5%; p = 0.013).

CONCLUSIONS

Healed plaques, a signature of prior plaque destabilization, were found at the culprit site in more than one-quarter of ACS patients. Such patients more frequently were diabetic, were hyperlipidemic, or had a history of MI. Healed plaques frequently showed OCT features of vulnerability with evidence of local and systemic inflammation. The combination of plaque vulnerability, local inflammation, and greater plaque burden in addition to systemic inflammation may outweigh the protective mechanism of plaque healing and predispose those plaques to develop occlusive thrombus.

摘要

背景

在发生心源性猝死的患者中，常可发现愈合的斑块，其形态学特征为分层表型。然而，目前尚缺乏体内数据。

目的

本研究旨在通过光学相干断层扫描（OCT）确定急性冠状动脉综合征（ACS）患者中急性罪犯斑块的愈合、形态特征和临床意义。

方法

共纳入 376 例接受急性罪犯病变 OCT 影像学检查的 ACS 患者（252 例 ST 段抬高型心肌梗死[MI]和 124 例非 ST 段抬高型 ACS）。根据 OCT 分层表现为不同光学密度层的分层表型存在与否，对患者进行分层。比较两组间临床和实验室数据、OCT 特征和 1 年预后。

结果

在 376 例患者中，有 108 例（28.7%）存在愈合斑块。愈合斑块患者中更常出现血脂异常、糖尿病和心肌梗死史（44.4%比 33.2%；p=0.041；35.2%比 23.5%；p=0.021；和 15.7%比 6.3%；p=0.009）。愈合斑块患者的高敏 C 反应蛋白显著升高（中位数 4.98mg/L [四分位距：1.00 至 11.32mg/L] 比 3.00mg/L [四分位距：0.30 至 10.15mg/L]；p=0.029）。斑块破裂（64.8%比 53.0%；p=0.039）、薄帽纤维粥样斑块（56.5%比 42.5%；p=0.016）和巨噬细胞堆积（81.1%比 63.4%；p=0.001）在分层组中更为常见。OCT 还显示，具有分层表型的斑块其面积狭窄更严重（79.2%±9.5%比 74.3%±14.3%；p=0.001）。两组间主要不良心血管事件的发生率相似，但愈合斑块患者的全因再住院率更高（32.7%比 16.5%；p=0.013）。