Tissue Characteristics of Residual Lesion in Patients With Acute Coronary Syndrome Caused by Plaque Rupture Versus Plaque Erosion: A Single-center, Retrospective, Observational Study

doi:10.21203/rs.3.rs-1493988/v1

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Research Article

Tissue Characteristics of Residual Lesion in Patients With Acute Coronary Syndrome Caused by Plaque Rupture Versus Plaque Erosion: A Single-center, Retrospective, Observational Study

https://doi.org/10.21203/rs.3.rs-1493988/v1

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Purpose

Patients with acute coronary syndrome (ACS), frequently caused by plaque rupture (PR), often have vulnerable plaques in residual and culprit lesions. However, whether this occurs in patients with plaque erosion (PE) as well is unknown. Therefore, we compared the tissue characteristics of residual lesions in patients with PE and those with PR.

Methods

The data of 88 patients with ACS who underwent both optimal coherence tomography (OCT) and intravascular ultrasound (IVUS) were retrospectively analyzed. Based on plaque morphology of the culprit lesions identified using OCT, patients were classified into PE and PR groups. The tissue characteristics of residual lesions evaluated using integrated backscatter IVUS were compared between the two groups after percutaneous coronary intervention.

Results

Patients were classified into the PE group (n=23) and PR group (n=35). The PE group had a significantly lower percent lipid volume and a higher percent fibrous volume than those of the PR group (35.0±17.8% vs. 49.2±13.4%, p<0.001; 63.2±17.1% vs. 50.3±13.1%, p=0.002, respectively). Receiver operating characteristic curve analysis revealed that the percent lipid volume in the residual lesions was a significant discriminant factor in estimating the plaque morphology of the culprit lesion (optimal cut-off value, <43.5%; sensitivity and specificity values were 73.9% and 68.6%, respectively).

Conclusions

Patients with PE had a significantly lower percent lipid volume and a significantly higher percent fibrous volume in the residual lesions than in those with PR, suggesting that the nature of coronary plaques in patients with PE is different from that in patients with PR.

Plaque rupture

plaque erosion

integrated backscatter intravascular ultrasound

optical coherence tomography

acute coronary syndrome

Plaque erosion (PE) is frequently observed as the second most common cause (26–41%) of acute coronary syndrome (ACS) after plaque rupture (PR) [1–5]. From a preventive point of view, careful insight into residual lesions in ACS patients could provide a better understanding of preventive strategies because these lesions could also be a substrate for subsequent coronary events [6, 7]. While previous intracoronary imaging studies have shown that patients with ACS have vulnerable plaques in residual lesions [8–11], PR and PE were not considered as separate causes of ACS. Considering PR is the main cause of ACS, the results of these studies might have reflected only the characteristics of PR. It is not well known whether multivessel vulnerability shown in patients having PR also applies to those having PE.

Intravascular ultrasound (IVUS) imaging provides deeper penetration than other intracoronary imaging modalities, such as optical coherence tomography (OCT), resulting in visualization of the entire vessel wall and is currently considered the gold standard to assess coronary plaque tissue characteristics. The addition of an integrated backscatter (IB) technique to IVUS imaging (IB-IVUS) aids in the volumetric assessment of coronary plaque characteristics that has an excellent correlation with histopathological findings [12]. This method has been used in many in vivo clinical studies [8, 13–17]. In the present study, we utilized IB-IVUS to evaluate the tissue characteristics of residual lesions in patients with PE and compared them with those in patients with PR.

Study Population

In this single-center, retrospective, observational study, consecutive patients with ACS who were admitted to the Aichi Medical University (Nagakute, Japan) from September 2017 to July 2019 and underwent both OCT and IVUS were included. Patients with ACS included those who suffered ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and unstable angina [18]. Patients whose culprit lesion was an in-stent lesion or graft-vessel lesion and those whose OCT or IVUS image quality was poor were excluded. This study was conducted in accordance with the principles of the Declaration of Helsinki established by the World Medical Association. The study protocol was approved by the Ethics Committee of Aichi Medical University (Nagakute, Japan), and all patients provided written informed consent.

OCT Examination and Imaging Analysis

The plaque morphology of the culprit lesions, which were determined based on electrocardiography, echocardiography, and coronary angiography findings, were evaluated using OCT after manual aspiration thrombectomy. Intracoronary images of the culprit lesions were acquired using a frequency-domain OCT system (ILUMIEN OPTIS™, Abbott Vascular, Santa Clara, CA, USA or LUNAWAVE®, Terumo Corporation, Tokyo, Japan). The technique of OCT image acquisition has been described elsewhere [19–21]. Briefly, OCT catheters (Dragonfly™, Abbott Vascular, Santa Clara, CA, USA or FastView®, Terumo Corporation, Tokyo, Japan) were advanced distally to the culprit lesion over a 0.014-inch guidewire. The OCT catheter pullbacks were performed during injection of 100% contrast medium from the guiding catheter, acquiring images at a speed of 36 mm/s with the Dragonfly™ catheter and 40 mm/s with the FastView® catheter. The OCT images were analyzed using a dedicated offline review system by two experienced investigators. The plaque morphologies of culprit lesions were classified as PE, PR, calcified nodule, and others on the basis of previously established criteria [2, 5]. PE was defined based on the presence of the attached thrombus overlying an intact and visualized plaque, luminal surface irregularity at the culprit lesion in the absence of thrombus, or attenuation of the underlying plaque by thrombus without superficial lipid or calcification immediately proximal or distal to the site of thrombus. PR was defined according to the presence of fibrous cap discontinuity with communication between the lumen and inner core of the plaque or cavity formation within the plaque. A calcified nodule was identified as a fibrous cap disruption detected over a calcified plaque characterized by protruding calcification, superficial calcium, or the presence of substantive calcium proximal and/or distal to the lesion. Patients who exhibited PE and those who did not were categorized into the PE group and PR group, respectively.

IVUS Examination and Imaging Analysis

After stenting the culprit lesion, IVUS examination of the culprit vessel was performed. The residual lesion was determined as a 5-mm segment located more than 5 mm proximal or 5 mm distal to the stented segment. IVUS imaging data were acquired with a VISICUBE™ IVUS imaging system using a 60-MHz mechanically rotating IVUS catheter (AltaView™, Terumo Corporation, Tokyo, Japan). After the IVUS catheter was advanced distally over a 0.014-inch guidewire, IVUS catheter pullbacks were performed using a motorized pullback device at a speed of 9.0 mm/s. The quantitative measurements of cross-sectional IVUS images were analyzed using manual tracing at 1-mm intervals throughout the lesions. Vessel, lumen, and plaque volumes, calculated using Simpson’s method, were standardized as volume index (volume/analyzed length, mm³/mm). Percent plaque volume was calculated as [(plaque volume/vessel volume) × 100, %] [22]. The lipid and fibrous characteristics of the residual lesions were also evaluated using IB-IVUS. The IB-IVUS images were analyzed using a computerized offline software (VISIATLAS™, Terumo Corporation, Tokyo, Japan). IB values for each tissue characteristic were calculated as the average power of the frequency components of the backscatter signal using a fast Fourier transform, measured in decibels and classified into four color-coded components: blue (lipid), green (fibrous), yellow (dense fibrosis), and red (calcification) [23]. The percentage of each tissue characteristic was automatically calculated as [(plaque volume/vessel volume) × 100, %].

Statistical Analysis

Data were expressed as mean ± standard deviation or as median and interquartile range with differences (95% confidence interval). Categorical variables were expressed as frequencies (%). Continuous variables were compared using the unpaired Student’s t-test, and categorical variables were compared using the chi-squared or Fisher’s exact test, where appropriate. Mann–Whitney U tests were performed for non-parametric data. Statistical significance was assumed at a p value of 0.05. Receiver operating characteristic (ROC) curve analysis was performed to assess the optimal cut-off value of percent lipid volume for estimating the plaque morphology of the culprit lesion. The optimal cut-off value was determined using the Youden’s index. Differences in the proportion of PE according to percent lipid volume were analyzed using the Cochrane–Armitage trend test. All statistical analyses were performed using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA) except for the Cochran–Armitage trend test, which was carried out using R software, version 3.6.1 (R Foundation for Statistical Computing, Vienna, Austria; available as a free download from http://www.r-project.org).

Patient Characteristics

A total of 88 patients with ACS were enrolled in the present study (Fig. 1), among whom 22 were excluded because their data could not be analyzed owing to poor OCT (n = 17) or IVUS (n = 5) images. After excluding 4 patients with calcified nodules and 4 with other morphologies, the data of 23 patients with PE and 35 patients with PR were compared in the present study. There were no significant differences in baseline clinical characteristics between the two groups (Table 1). In terms of the location of culprit lesions, the left anterior descending artery (LAD) was most frequently affected (69.6%), followed by the right coronary artery (RCA, 17.4%), whereas in the PR group, the location was equally distributed among the LAD and the RCA (48.6% and 42.9%, respectively).

Table 1

Patient Characteristics
Variable	All patients (n = 58)	Plaque erosion (n = 23)	Plaque rupture (n = 35)	p value
Age, years	67.2 ± 13.8	66.8 ± 14.3	67.4 ± 13.5	0.863
Male sex, n (%)	41 (70.7)	16 (69.6)	25 (71.4)	0.879
BMI, kg/m²	23.6 ± 3.7	23.5 ± 2.6	23.7 ± 4.4	0.876
Clinical history, n (%)
Dyslipidemia	30 (51.7)	9 (39.1)	21 (60.0)	0.120
Hypertension	31 (53.4)	9 (39.1)	22 (62.9)	0.076
Smoking	14 (24.1)	4 (17.4)	10 (28.6)	0.305
Diabetes mellitus	19 (32.8)	9 (39.1)	10 (28.6)	0.402
Prior PCI	2 (3.4)	0 (0)	2 (5.7)	0.352
Clinical presentation, n (%)
STEMI	34 (58.6)	11 (47.8)	23 (65.7)	0.258
NSTE-ACS	24 (41.4)	12 (52.2)	12 (34.3)	0.258
Number of diseased vessels, n (%)
1 vessel	30 (51.7)	15 (65.2)	15 (42.9)	0.055
2 vessels	22 (37.9)	7 (30.4)	15 (42.9)
3 vessels	6 (10.3)	1 (4.3)	5 (14.3)
Target plaque location, n (%)
Left anterior descending	33 (56.9)	16 (69.6)	17 (48.6)	0.349
Left circumflex	6 (10.3)	3 (13.0)	3 (8.6)
Right	19 (32.8)	4 (17.4)	15 (42.9)
Blood lipid levels, mg/dL
Triglycerides	133.4 [87.0–171.0]	140.9 [82.8–140.0]	141.4 [85.0–171.0]	0.984
HDL cholesterol	46.4 ± 10.6	44.9 ± 9.9	47.7 ± 10.5	0.300
LDL cholesterol	121.9 ± 31.5	115.3 ± 27.0	127.1 ± 33.6	0.150
Medication, n (%)
Aspirin	8 (13.8)	6 (26.1)	2 (5.7)	0.036
Clopidogrel	3 (5.2)	1 (4.3)	2 (5.7)	0.656
Statins	8 (13.8)	1 (4.3)	7 (20.0)	0.093
Calcium-channel blockers	12 (20.7)	5 (21.7)	7 (20.0)	0.562
Angiotensin-converting enzyme inhibitors	1 (1.7)	0 (0)	1 (2.9)	0.603
Angiotensin II type 1 receptor antagonists	13 (22.4)	3 (13.0)	10 (28.6)	0.165
β-blockers	3 (5.2)	1 (4.3)	2 (5.7)	0.656
Values are presented as mean ± SD, n (%), or median (interquartile range).
BMI: body mass index, PCI: percutaneous coronary intervention, STEMI: ST-elevation myocardial infarction, NSTE-ACS: non-ST elevation-acute coronary syndrome, HDL: high density lipoprotein, LDL: low density lipoprotein

Quantitative Parameters in Grayscale IVUS and IB-IVUS Analyses of Residual Lesions

The grayscale IVUS analysis of residual lesions showed that vessel volume and plaque volume were significantly smaller in the PE group than in the PR group (64.8 ± 24.1 mm³ vs. 76.2 ± 17.9 mm³, p = 0.042; 20.9 ± 11.1 mm³ vs. 30.7 ± 10.7 mm³, p = 0.01, respectively). IB-IVUS analysis revealed that the percent lipid volume was significantly lower in the PE group than in the PR group (35.0 ± 17.8% vs. 49.2 ± 13.4%, p < 0.001), whereas the percent fibrous volume was significantly higher in the PE group than in the PR group (63.2 ± 17.1% vs. 50.3 ± 13.1%, p = 0.002; Table 2). Figure 2 shows representative images of grayscale IVUS and IB-IVUS in residual lesions of the PE and PR groups.

Table 2

Residual Lesion Analysis Using QCA, Grayscale IVUS, and IB-IVUS
Variable	Plaque erosion (n = 23)	Plaque rupture (n = 35)	p value
QCA analysis
Reference diameter, mm	3.3 ± 0.6	3.3 ± 0.7	0.804
Minimal lumen diameter, mm	3.0 ± 0.6	3.1 ± 0.7	0.783
Percent diameter stenosis, %	8.1 ± 4.4	8.0 ± 5.1	0.925
Grayscale IVUS
Vessel volume, mm³	64.8 ± 24.1	76.2 ± 17.9	0.042
Lumen volume, mm³	43.9 ± 17.4	45.5 ± 12.3	0.672
Plaque volume, mm³	20.9 ± 11.1	30.7 ± 10.7	0.010
IB-IVUS analysis
Lipid volume, %	35.0 ± 17.8	49.2 ± 13.4	0.001
Fibrous volume, %	63.2 ± 17.1	50.3 ± 13.1	0.002
Calcification volume, %	1.6 ± 1.7	0.7 ± 0.7	0.032
QCA: quantitative coronary angiography, IVUS: intravascular ultrasound

Predictive Value of Residual Lesion Characteristics for the Estimation of Culprit Lesion Morphology

ROC curve analysis revealed that percent lipid volume in residual lesions was a significant discriminant factor in estimating the plaque morphology of the culprit lesion (p < 0.001), with an area under the curve of 0.738. The optimal cut-off value of percent lipid volume was < 43.5%, and the sensitivity and specificity values were 73.9% and 68.6%, respectively. The proportional analyses stratified according to percent lipid volume in residual lesions showed that the frequency of PE in the culprit lesions increased when the percent lipid volume in the residual lesions decreased (p < 0.001 for trend) (Fig. 3). All the patients with a percent lipid volume < 20% in residual lesions exhibited PE in the culprit lesion. In contrast, among patients with percent lipid volume ≥ 50% in residual lesions, only 21.7% of them demonstrated PE in the culprit lesion (Fig. 4).

Our study revealed that the tissue characteristics of residual lesions differed between patients with PE and those with PR. Furthermore, the plaque morphology of the culprit lesions could be estimated based on the plaque characteristics of residual lesions. To the best of our knowledge, this is the first study to evaluate the tissue characteristics of residual lesions in patients with PE.

Tissue Characteristics of Residual Lesions in Patients With PE and Those With PR

In this study, IB-IVUS analyses demonstrated that patients in the PE group had a lower percent lipid volume and a higher percent fibrous volume in residual lesions than those in the PR group. To date, there are limited data on the characteristics of residual lesions in patients with PE; however, several reports on culprit lesions exist. A previous pathological study has demonstrated that culprit lesions in patients with PE have more fibrous tissue, less necrotic core, and less macrophage infiltration than those in patients with PR [1]. Furthermore, several OCT studies have revealed similar findings regarding the tissue characteristics of culprit lesions in patients with PE; these lesions have lower prevalence of lipid plaque, smaller lipid arc, and less macrophage infiltration than those in patients with PR [2, 5, 24]. These results suggest that culprit lesions of patients with PE have less plaque vulnerability and less inflammation than those of patients with PR.

Sugiyama et al. evaluated the morphological features of residual lesions using OCT in 17 patients with PE [25]. The residual lesions in patients with PE had a lower prevalence of plaque rupture, macrophage accumulation, microvessels, and spotty calcium than those in patients with PR, indicating that patients with PE had lower levels of pancoronary vulnerability than those with PR. The present study, which focused on histological characteristics, rather than morphological characteristics, of residual lesions using IB-IVUS analysis, showed lower lipid tissue and higher fibrous tissue in the PE group, supporting the concept of less inflammation throughout the coronary tree in patients with PE. Currently, aggressive lipid-lowering therapy is uniformly recommended for all patients with ACS for secondary prevention [26, 27]. However, the results of our study suggest that the tissue characteristics of residual lesions differ between patients with PE and those with PR, and the level of plaque vulnerability is lower in patients with PE than those with PR. Therefore, the intensity of lipid-lowering therapy for secondary prevention may need to be individually modified according to the mechanism of ACS and the extent of plaque vulnerability.

Estimation of Plaque Morphology of Culprit Lesions Using Residual Lesion Characteristics

In the present study, the plaque morphology of culprit lesions could be estimated based on the data regarding residual lesion characteristics obtained using IB-IVUS analyses. Identifying the plaque morphology of the culprit lesion provides useful information about the underlying mechanism of coronary thrombosis [28–31]. The treatment strategy may be changed depending on the underlying mechanism of coronary thrombosis [32, 33]. The EROSION study demonstrated that conservative treatment with anti-thrombotic therapy without stenting may be an option for lesions related to PE [32, 33]. OCT has been generally used for the in vivo evaluation of plaque morphology of culprit lesions because of its high resolution [34]. However, there are several limitations in using OCT, such as requirement for blood clearance, limited soft tissue penetration, and additional contrast medium use, which often precludes detailed assessment of plaque morphology [35–37]. Moreover, in OCT images, a fresh thrombus sometimes causes a blind spot, especially in cases of ACS, resulting in misdiagnosis of the plaque’s morphology [38]. As shown in the present study, assessments of residual lesion characteristics using IB-IVUS might facilitate the diagnosis of plaque morphology of culprit lesions in patients with ACS.

Despite the abovementioned results, the present study has several limitations. First, this was a single-center study involving a relatively small population; therefore, the results are hypothesis-generating. Larger prospective studies are warranted to validate our results. Second, the present study included patients with ACS that is strongly associated with thrombus formation, which might have potentially influenced the results of the IB-IVUS analysis. Third, we defined a residual lesion as a 5-mm segment proximal or distal to the culprit lesion, which comprised only a small part of the entire coronary artery. Therefore, the results of the residual lesion assessment might not reflect the results for all the coronary arteries.

In conclusion, tissue characteristics of residual lesions differed between patients with PE and those with PR. Patients with PE had a significantly lower percent lipid volume and a significantly higher percent fibrous volume in residual lesions compared with those of patients with PR.

All study participants provided informed consent, and the study design was approved by the ethics committee of the Aichi Medical University (2018-H310).

Conflicts of Interest

The authors have no relevant financial or non-financial interests to disclose.

Financial Support

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Disclosures

None.

Author Contributions

Concept and design: All authors. Acquisition, analysis, or interpretation of data: all authors. Critical revision of the mamusucript for important intellectual content: All authors.

Acknowledgments

The authors would like to thank all the staff and patients who contributed to this study.

DATA AVAILABILITY

The deidentified participant data will not be shared.

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No competing interests reported.

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Tissue Characteristics of Residual Lesion in Patients With Acute Coronary Syndrome Caused by Plaque Rupture Versus Plaque Erosion: A Single-center, Retrospective, Observational Study

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Abstract

Figures

Introduction

Methods

Study Population

OCT Examination and Imaging Analysis

IVUS Examination and Imaging Analysis

Statistical Analysis

Results

Patient Characteristics

Quantitative Parameters in Grayscale IVUS and IB-IVUS Analyses of Residual Lesions

Predictive Value of Residual Lesion Characteristics for the Estimation of Culprit Lesion Morphology

Discussion

Tissue Characteristics of Residual Lesions in Patients With PE and Those With PR

Estimation of Plaque Morphology of Culprit Lesions Using Residual Lesion Characteristics

Declarations

References

Additional Declarations

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