Relation of Ruptured Plaque Culprit Lesion Phenotype and Outcomes in Patients With ST Elevation Acute Myocardial Infarction

Sang Wook KimYoung Joon HongGary S. MintzSung Yun LeeJun Hyung DohSeong Hoon LimHyun Jae KangSeung Woon RhaJung Sun KimWang-Soo LeeSeong Jin OhSahng LeeJoo Yong HahnJin Bae LeeJang Ho BaeSeung Ho HurSeung Hwan HanMyung Ho JeongYoung Jo Kim
Dept. of Internal Medicine (내과학)
Issue Date
American Journal of Cardiology, Vol.109(6) : 794-799, 2012
We used virtual histology intravascular ultrasound (VH-IVUS) to assess culprit plaque rupture in 172 patients with ST-segment elevation acute myocardial infarction. VH-IVUSdefined thin-capped fibroatheroma (VH-TCFA) had necrotic core (NC) >10% of plaque area, plaque burden >40%, and NC in contact with the lumen for >3 image slices. Ruptured plaques were present in 72 patients, 61% of which were located in the proximal 30 mm of a coronary artery. Thirty-five were classified as VH-TCFA and 37 as non-VHTCFA. Vessel size, lesion length, plaque burden, minimal lumen area, and frequency of positive remodeling were similar in VH-TCFA and non-VH-TCFA. However, the NC areas within the rupture sites of VH-TCFAs were larger compared to non-VH-TCFAs (p 0.002), while fibrofatty plaque areas were larger in non-VH-TCFAs (p <0.0001). Ruptured plaque cavity size was correlated with distal reference lumen area (r 0.521, p 0.00002), minimum lumen area (r 0.595, p <0.0001), and plaque area (r 0.267, p 0.033). Sensitivity and specificity curve analysis showed that a minimum lumen area of 3.5 mm2, a distal reference lumen area of 7.5 mm2, and a maximum NC area of 35% best predicted plaque rupture. Although VH-TCFA (35 of 72) was the most frequent phenotype of plaque rupture in ST-segment elevation myocardial infarction, plaque rupture also occurred in non-VH-TCFA: pathologic intimal thickening (8 of 72), thick-capped fibroatheroma (1 of 72), and fibrotic (14 of 72) and fibrocalcified (14 of 72) plaque. In conclusion, not all culprit plaque ruptures in patients with ST-segment elevation myocardial infarction occur as a result of TCFA rupture; a prominent fibrofatty plaque, especially in a proximal vessel, may be another form of vulnerable plaque. Further study should identify additional factors causing plaque rupture. © 2012 Elsevier Inc. All rights reserved. (Am J Cardiol 2012;109: 794–799)
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