Vuln shape aha 2005
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Transcript of Vuln shape aha 2005
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Perspective:Vulnerable Plaque
…or vessels, patients or ??
Robert S. Schwartz, MDMinneapolis Heart Institute
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
How to Cure Human Disease
1. Define the Disease2.Associate it reliably3.Find the Disease4. Deliver the ‘Fix’
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Arterial Inflammation
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Find the DiseaseImaging Technology
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
3 Autopsy Derived GroupsAcute MI
18 patients/337 segments
Stable Angina 5 Patients/76 segments
Controls (no CAD)9 Patients/111 segments
Coronary Inflammation
Is Diffuse
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Inflammatory Cell Count
Macrophages/MonocytesCD-68 Positivity
T-LymphocytesCD-3 Positivity
Coronary Inflammation
Is Diffuse
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
IRA Segments
AMI
Non-IRA segments
of AMI group
Controls
CD68 positive cells monocytes/macrophages
38.0 + 7.9%
35.3 + 4.7%
1.0+ 2.9%
CD3 positive cells (T-lymphocytes)
17.7 + 3.5%
20.9+ 4.1%
7.6 + 1.6%
Coronary Artery Inflammation Is DiffuseJACC April 2005 Mauriello, Sangiorgi, Fratoni, Palmieri, Bonanno, Anemona Schwartz, Spagnoli
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Coronary Inflammation Is Diffuse
05
10152025303540
IRA Non-IRA Control
Macrophages Lymphocytes
JACC April 2005 Mauriello, Sangiorgi, Fratoni, Palmieri, Bonanno, Anemona Schwartz, Spagnoli
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Vulnerable Plaque:
Detection
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
ThermographyWill Thermography will easily detect and localize vulnerable plaque?
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Thermography
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Porcine Proximal LCX10 days
Histopathology:Chronic, superficial inflammation, mainly mononuclear cells ¾ of the lumen circumflex
Temperature:Circumferential and significantly increasedvessel wall temperature above 1.0°C
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Caveat:Thermography and thermal
heterogeneity measures appear highly flow dependent. The methods and devices can be technically challenging. Major differences exist across published studies.
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
MRIImaging
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The MinneapolisHeart Institute
Self-contained portable MRI
catheter
Catheter Based MRI Imaging
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The MinneapolisHeart Institute
Ex-vivo MR imaging: human coronary arteries
Adaptive intimal thickening
LAD atheroma
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
VulnerabilityBetter Detection Methods
MSCTA
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The MinneapolisHeart Institute
Coronary Ruptured Plaque (CTA) Aortic Penetrating Ulcer (MRA)
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The MinneapolisHeart Institute
Is Not ‘Soft Plaque”MSCTA visualizes wellQuestions:
Prevalence of isolated Uncalcified Plaque (no associated calcified plaque)
Risk Factors associated
CTA and Uncalcified Plaque
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The MinneapolisHeart Institute
506 unselected patients scanned for chest pain16-Slice MSCTA
CTA and Uncalcified Plaque
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
30% (124/506 patients) had no calcification
CTA and Uncalcified Plaque
30%70%
No Calcification
Calcification
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
44% (55/124 patients) had no plaque
CTA and Uncalcified Plaque
30%70%
No Calcification
Calcification
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
51% (63/124patients) had uncalcified plaque without severe stenosis
CTA and Uncalcified Plaque
51%
49%
No Stenosis
Stenosis
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
5% (6/124 patients) of Uncalcified Plaque had significant stenosis
CTA and Uncalcified Plaque
5%
95%
SignificantStenosisNo SignficiantStenosis
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Risk Factors and all uncalcified plaque83% Smokers (former/current)
98% of patients with 0-3 Risk factors had no plaque or <50% Stenosis
86% of patients with > 4 Risk factors had UCP and/or significant stenosis
No patient with <2 Risk Factors had uncalcified plaque
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Uncalcified plaque is prevalent in patients with chest pain
Smoking may have significant impact on UCP formation.
UCP prevalence is highly dependent on aggregate coronary risk.
MSCTA appears useful for detecting both calcified and noncalcified coronary plaque.
MSCTA and Uncalcified Plaque
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Observation:Significant technical
developments are needed for MRI. Problems of Spatial and Temporal Resolution, and Acquistion remain a major impediment to clinical coronary imaging in living patients.
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The MinneapolisHeart Institute
Optical Coherence
Tomography
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Culprit Lesion
M-OA
M-LC
A-WJ
Unstable
E-KK M-UM
E-IM E-JS
A-MK
RECENT MI
UNSTABLE ANGINA
UNSTABLE ANGINAJust proximal to stented lesion
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The MinneapolisHeart Institute
CaveatIntravascular Imaging can localize thin-cap fibroadenoma and lipid-laden regions of vulnerability.
But what does it mean?
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The MinneapolisHeart Institute
Raman Spectroscopy
Scepanvic O, Galindo LH, Feld MS
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Now that we aren’t certain about diagnoses, what about therapy?
Perspective: Imaging Vulnerable Plaque
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The MinneapolisHeart Institute
% % with with EvenEven
tt
00 33 1818 2121 2424 2727 303066 99 1212 1515
2020
1515
1010
55
00
Months of Follow-up
All-Cause Death, Non-Fatal MI, or Urgent Revascularization
Pravastatin 40mgPravastatin 40mg16.7%16.7%
Atorvastatin 80mgAtorvastatin 80mg12.9%12.9%
25% RR25% RRP = 0.0004P = 0.0004
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
16.7
20.5
33.3
16.7
6.43.9
1.3 1.30 0 0 0 0
05
101520253035
Perc
ent (
%)
10 20 30 40 50 60 70 80 90 100
110
120
130
millimeters (mm) Prox Mid Distal
p = 0.003
Distribution of Acute Coronary OcclusionsLeft Anterior Descending Artery
(Normalized Segment Analysis)
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
0102030405060708090
1000 10 20 30 40 50 60 70 80 90 100
110
120
130
millimeters (mm)
Perc
ent (
%)
Acute Coronary Occlusions by Distance fromLeft Anterior Descending Artery Ostium
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
How to Cure Human Disease
1. Define the DiseaseNot Yet
2.Associate it reliablyNot Yet
3.Find the DiseaseNot Yet
4. Deliver the ‘Fix’Not Yet
The Minneapolis HeartInstitute Foundation
The MinneapolisHeart Institute
Perspective:Vulnerable Plaque
…or vessels, patients or ??
Robert S. Schwartz, MDMinneapolis Heart Institute