Dear Member of AEHA

1
(No Transcript)
2
Dear Member of AEHA
Thank you for participating in the First
Vulnerable Patient Symposium. This educational CD
contains multiple PowerPoint slide presentations
along with animated movies. Also included the
Part I and II of the Vulnerable Patient
Manuscript.
AEHA would like to thank the generous support of
Amersham Health, CV Therapeutics, diaDexus, and
American Heart Technologies.
3
Introducing

• The Vulnerable Patient Consensus Statement

Published in
4
Circulation Journal Vol108, No14 October 7, 2003
5
Abstract
Circulation Journal Vol108, No14 October 7, 2003
6
Naghavi et al. Circulation. 20031081664
7
Naghavi et al. Circulation. 20031081664
8
(No Transcript)
9
Underlying Pathologies of "Culprit" Coronary
Lesions
Ruptured plaques (  70)

•  Stenotic (  20)

•  Nonstenotic (  50)

Nonruptured plaques (  30)

•  Erosion

•  Calcified nodule

•  Others/Unknown

Adapted from Falk and associates,6 Davies,7 and
Virmani and colleagues.7
Naghavi et al. Circulation. 20031081664
10
Descriptions Used by Pioneers for Culprit Plaques
Description Used
Year
Author
Plaque rupture
1931
Olcott
Rupture of atheromatous abscess
1934
Leary
Rupture-induced occlusion
1938
Wartman
Plaque fissure
1940
Horn
Plaque erosion
1957
Helpern
Plaque thrombosis
1961
Crawford
Plaque ulceration
1963
Gore
Thrombogenic gruel
1964
Byers
Plaque rupture
1966
Chapman
Plaque rupture
1966
Constantinides
Plaque rupture
Friedman
1966
Naghavi et al. Circulation. 20031081664
11
Plaque rupture illustrated in 1966
12
The Challenge of Terminology

• Culprit Plaque A Retrospective Term

• Vulnerable Plaque A Prospective Term

Vulnerable Plaque Future Culprit Plaque
Naghavi et al. Circulation. 20031081664
13
Criteria for Defining Vulnerable Plaque Based on
the Study of Culprit Plaques
Major criteria

•        Active inflammation (monocyte/macrophage
  and sometimes T-cell infiltration)

•        Thin cap with large lipid core

•        Endothelial denudation with superficial
  platelet aggregation

•        Fissured plaque

•        Critical Stenosis

Minor criteria

•        Superficial calcified nodule

•        Glistening yellow

•        Intraplaque hemorrhage

•        Endothelial dysfunction

•        Outward (positive) remodeling

Naghavi et al. Circulation. 20031081664
14
Markers of Vulnerability at the Plaque/Artery
Level
Plaque Morphology / Structure
    

•            Plaque cap thickness

•            Plaque lipid core size

•            Plaque stenosis (luminal narrowing)

•            Remodeling (expansive vs constrictive
  remodeling)

•            Color (yellow, glistening yellow,
  red, etc)

•            Collagen content versus lipid
  content, mechanical stability (stiffness and
  elasticity)

•            Calcification burden and pattern
  (nodule vs scattered, superficial vs deep, etc)

•            Shear stress (flow pattern throughout
  the coronary artery)

Naghavi et al. Circulation. 20031081664
15
Markers of Vulnerability at the Plaque/Artery
Level
Plaque Activity / Function

•            Plaque inflammation (macrophage
  density, rate of monocyte infiltration and
• density of activated T cell)

•            Endothelial denudation or dysfunction
  (local NO production, anti-
• /procoagulation properties of the
  endothelium)

•            Plaque oxidative stress

•            Superficial platelet aggregation and
  fibrin deposition (residual mural
• thrombus)

•            Rate of apoptosis (apoptosis protein
  markers, coronary microsatellite, etc)

•            Angiogenesis, leaking vasa vasorum,
  and intraplaque hemorrhage

•            Matrix-digesting enzyme activity in
  the cap (MMPs 2, 3, 9, etc)

•            Certain microbial antigens (eg,
  HSP60, C. pneumoniae)

Naghavi et al. Circulation. 20031081664
16
Markers of Vulnerability at the Plaque/Artery
Level
Pan-Arterial

•        Transcoronary gradient of serum markers
  of vulnerability

•        Total coronary calcium burden

•        Total coronary vasoreactivity
  (endothelial function)

•        Total arterial burden of plaque including
  peripheral (eg, carotid IMT)

Naghavi et al. Circulation. 20031081664
17
The most common type
Naghavi et al. Circulation. 20031081664
18
The Most Common Type of Vulnerable Plaque
Naghavi et al. Circulation. 20031081664
19
Non-Stenotic Vulnerable Plaques overall are More
Dangerous Since they are far More Frequent than
Stenotic Ones
Naghavi et al. Circulation. 20031081664
20
Click to view the Natural History of
Atherosclerosis and Vulnerable Plaques
Click here to escape the movie
21
Both Morphology and Activity Assessments are
Needed
Naghavi et al. Circulation. 20031081664
22
(No Transcript)
23
Serologic Markers of Vulnerability (Reflecting
Metabolic and Immune Disorders)

• Abnormal lipoprotein profile (e.g. high LDL,
  low HDL, abnormal LDL and HDL size density,
  lipoprotein (a), Lp-PLA2 )
• Serum markers of insulin resistance syndrome
  (e.g. diabetes, hyper triglyceridemia )
• Non-specific markers of inflammation (e.g.
  hsCRP, CD40L, ICAM-1, VCAM-1, P-selectin,
  leukocytosis, and other serologic markers related
  to the immune system. These markers may not be
  specific for atherosclerosis or plaque
  inflammation)
• Specific markers of immune activation (e.g.
  anti-LDL antibody, anti-HSP antibody)
• Markers of lipid-peroxidation (e.g. ox-LDL and
  ox-HDL)
• Homocysteine
• Pregnancy-associated plasma protein A (PAPP-A)
• Circulating apoptosis marker(s) (e.g., Fas/Fas
  ligand, not specific to plaque)
• Asymmetric dimethylarginine (ADMA) /
  dimethylarginine dimethylaminohydrolase
  (DDAH)
• Circulating nonesterified fatty acids (e.g.
  NEFA)

Naghavi et al. Circulation. 20031081664
24
Blood Markers of Vulnerability (Reflecting
Hypercoagulability)

• Markers of blood hypercoagulability (e.g.
  fibrinogen, D-dimer, and factor V Leiden)
• Increased platelet activation and aggregation
  (e.g., gene polymorphisms of platelet
  glycoproteins IIb/IIIa, Ia/IIa, and Ib/IX)
• Increased coagulation factors (e.g., clotting
  of factors V, VII, VIII, von Willebrand factor,
  XIII)
• Decreased anticoagulation factors (e.g.,
  proteins S, C, thrombomodulin, and antithrombin
  III)
• Decreased endogenous fibrinolysis activity
  (e.g. reduced t-PA, increased PAI-1, certain
  PAI-1 polymorphisms)
• Prothrombin mutation (e.g. G20210A)
• Other thrombogenic factors (e.g.,
  anticardiolipin antibodies, thrombocytosis,
  sickle cell disease, polycythemia, diabetes
  mellitus, hypercholesterolemia,
  hyperhomocysteinemia)
• Increased viscosity
• Transient hypercoagulability (e.g. smoking,
  dehydration, infection, adrenergic surge,
  cocaine, estrogens, postprandial, etc.)

Naghavi et al. Circulation. 20031081664
25
(No Transcript)
26
Conditions and Markers Associated with Myocardial
Vulnerability

• With atherosclerosis-derived myocardial ischemia
  as shown by
• ECG abnormalities
• During rest
• During stress test
• Silent ischemia (e.g. ST changes on Holter
  monitoring)
• Perfusion and viability disorder
• PET scan
• SPECT
• Wall motion abnormalities
• - Echocardiography
• - MR imaging
• - X-ray ventriculogram
• - MSCT

Naghavi et al. Circulation. 20031081664
27
Conditions and Markers Associated with Myocardial
Vulnerability

• Without atherosclerosis-derived myocardial
  ischemia
• Sympathetic hyperactivity
• Impaired arterial baroreflex
• Left ventricular hypertrophy
• Cardiomyopathy (dilated, hypertrophic,
  restrictive, or right ventricular)
• Valvular disease (aortic stenosis and mitral
  valve prolapse)
• Electrophysiologic disorders
• - Long QT syndrome, Brugada syndrome,
  Wolff-Parkinson-White syndrome, sinus and
  atrioventricular conduction disturbances,
  catecholaminergic polymorphic ventricular
  tachycardia, T-wave alternans, drug-induced
  torsades de pointes
• Commotio cordis
• Anomalous origination of a coronary artery
• Myocarditis
• Myocardial bridging

Naghavi et al. Circulation. 20031081664
28
Available Techniques for Electrophysiologic Risk
Stratification of Vulnerable Myocardium
Diagnostic Criteria - Arrhythmia - QT
dispersion - QT dynamics - T wave alternans
- Ventricular late potentials - Heart rate
variability Diagnostic Techniques Non-Invasive
Resting ECG Stress ECG
Ambulatory ECG Signal
averaged electrocardiogram (SAECG)
Surface high-resolution ECG Invasive
Programmed ventricular stimulation (PVS)
Real-time 3D magnetic-navigated activation map
Naghavi et al. Circulation. 20031081664
29
Naghavi et al. Circulation. 20031081664
30
Click to view the Vulnerable Plaque-Blood-Myocardi
um Movie
Click here to escape the movie
31
The VP Pyramid
Outlines for Annual
Screening
Diagnosis
Treatment
gtgt
gtgt
32
CVD Genotyping?
Naghavi et al. Circulation. 20031081664
33
(No Transcript)
34
Annual Cost of Heart Attacks in the USA
35
Stay Tuned for the Guidelines
in Part III and IV
Screening
Diagnosis
Treatment
gtgt
gtgt
36
HELP AEHA SAVE VULNERABLE PATIENTS
37
(No Transcript)