Antithrombotic Therapy Alone for Plaque Erosion
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- intravascular ultrasound
- myocardial infarction
- optical coherence
- plaque erosion
- plaque rupture
The underlying atherosclerotic substrate of patients presenting with an acute coronary syndrome (ACS) is highly heterogeneous.1–3 However, intracoronary thrombus (platelet versus fibrin rich) is ubiquitous, and the resulting clinical syndrome derives from its ability to occlude the coronary lumen (completely versus partially, permanently versus transiently) impeding coronary flow. Alternatively, the underlying culprit plaque seating on the vessel wall may have largely distinct phenotypic characteristics.1–3 In most patients (≈65%–70%), plaque rupture (PR) constitutes the responsible pathological substrate.1,2 PR represents by far the most frequent cause of ST-segment–elevation myocardial infarction (STEMI). PR originates from thin-cap fibroatheromas, frequently named high-risk or vulnerable plaques that eventually rupture promoting intracoronary thrombosis. These are characterized by a thin cap (<65 μm), frequently heavily infiltrated by macrophages releasing metalloproteinases, overlying a superficial, large, highly thrombogenic necrotic core. Thin-cap fibroatheromas have a large plaque burden (>75% cross sectional area) although no necessarily cause severe lumen obstruction as they typically experience expansive vessel remodeling.1,2 PRs tend to occur at the shoulder of these plaques and are associated with large red thrombi. At the other end of the spectrum, a minority (≈5%–10%) of patients with ACS present a complicated calcified coronary nodule.1–4 There is scarce information on the pathophysiology of this rare substrate that tends to occur in patients elderly or with chronic kidney disease, in heavily calcified vessels, particularly at hinge points of the right coronary artery where coronary torsion is increased.1,2,4
See Article by Xing et al
Finally, plaque erosion (PE) accounts for a significant number (≈20%–25%) of patients with ACS.1–5 However, the in vivo diagnosis …