Department of Cardiology, Second Affiliated Hospital of Harbin Medical University, Harbin, China; Key Laboratory of Myocardial Ischemia, Chinese Ministry of Education, Harbin, China.
Cardiovascular Research Foundation, New York, New York, USA.
JACC Cardiovasc Imaging. 2021 Jun;14(6):1235-1245. doi: 10.1016/j.jcmg.2020.07.047. Epub 2020 Oct 28.
This study sought to investigate nonculprit plaque characteristics in patients with ST-segment elevation myocardial infarction (STEMI) presenting with plaque erosion (PE) and plaque rupture (PR). Pancoronary vulnerability was considered at nonculprit sites: 1) the CLIMA (Relationship Between OCT Coronary Plaque Morphology and Clinical Outcome) study (NCT02883088) defined high-risk plaques with simultaneous presence of 4 optical coherence tomography (OCT) features (minimum lumen area <3.5 mm; fibrous cap thickness [FCT] <75 μm; maximum lipid arc >180º; and macrophage accumulation); and 2) the presence of plaque ruptures or thin-cap fibroatheromas (TCFA).
PE is a unique clinical entity associated with better outcomes than PR. There is limited evidence regarding pancoronary plaque characteristics of patients with culprit PE versus culprit PR.
Between October 2016 and September 2018, 523 patients treated by 3-vessel OCT at the time of primary percutaneous intervention were included with 152 patients excluded from final analysis.
Overall, 458 nonculprit plaques were identified in 202 STEMI patients with culprit PE; and 1,027 nonculprit plaques were identified in 321 STEMI patients with culprit PR. At least 1 CLIMA-defined OCT nonculprit high-risk plaque was seen in 11.4% of patients with culprit PE, but twice as many patients were seen with culprit PR (25.2%; p < 0.001). This proportion was also seen when individual high-risk features were analyzed separately. When patients with PE were divided by a heterogeneous substrate (fibrous or lipid-rich plaque) underlying the culprit site, the prevalence of nonculprits with FCT <75 μm, macrophages, and TCFA showed a significant gradient from PE to PE to PR. Interestingly, nonculprit rupture was rarely found in patients with culprit PE (1.9%), although it was exhibited with comparable prevalence in patients with culprit PE (16.3%) versus PR (17.8%). Culprit PE predicted decreased pancoronary vulnerability independent of conventional risk factors.
STEMI patients with culprit PE have a limited pancoronary vulnerability that may explain better outcomes in these patients than in STEMI patients with culprit PR.
本研究旨在探讨 ST 段抬高型心肌梗死（STEMI）患者中斑块侵蚀（PE）和斑块破裂（PR）患者的非罪犯斑块特征。在非罪犯部位考虑了全冠状动脉易损性：1）CLIMA（光学相干断层扫描冠状动脉斑块形态与临床结局的关系）研究（NCT02883088）定义了同时存在 4 种光学相干断层扫描（OCT）特征的高危斑块（最小管腔面积<3.5mm；纤维帽厚度[FCT] <75μm；最大脂质弧> 180°；巨噬细胞堆积）；2）存在斑块破裂或薄帽纤维粥样瘤（TCFA）。
PE 是一种独特的临床实体，其预后优于 PR。关于罪犯性 PE 与罪犯性 PR 患者的全冠状动脉斑块特征，证据有限。
2016 年 10 月至 2018 年 9 月，对行直接经皮冠状动脉介入治疗的 523 例患者进行了 3 血管 OCT 检查，其中 152 例患者被排除在最终分析之外。
在 202 例罪犯性 PE 的 STEMI 患者中发现了 458 个非罪犯斑块；在 321 例罪犯性 PR 的 STEMI 患者中发现了 1027 个非罪犯斑块。在 11.4%的罪犯性 PE 患者中发现了至少 1 个 CLIMA 定义的 OCT 非罪犯高危斑块，但在罪犯性 PR 患者中发现的比例则为两倍（25.2%；p<0.001）。当分别分析单个高危特征时，也观察到了这种比例。当根据罪犯部位下的基质（纤维或富含脂质的斑块）将 PE 患者进行分组时，非罪犯 FCT<75μm、巨噬细胞和 TCFA 的高危斑块比例从 PE 到 PR 呈显著梯度分布。有趣的是，在罪犯性 PE 患者中很少发现非罪犯破裂（1.9%），尽管在罪犯性 PE 患者（16.3%）和 PR 患者（17.8%）中均表现出相似的患病率。罪犯性 PE 预测全冠状动脉易损性降低，独立于传统危险因素。
STEMI 患者的罪犯性 PE 具有有限的全冠状动脉易损性，这可能解释了与罪犯性 PR 患者相比，这些患者的预后更好。
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