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Arithmetic of vulnerable plaques for noninvasive imaging

Nature Clinical Practice Cardiovascular Medicine volume 5, pages S2–S10 (2008)Cite this article

Abstract

Sudden cardiac death and acute myocardial infarction often occur as the first manifestation of coronary artery disease. Otherwise asymptomatic individuals with subclinical atherosclerosis almost always have a classic risk-factor profile and it is essential that they are identified before the occurrence of an acute coronary event. The ability to recognize such individuals requires the development of strategies that can localize unstable atherosclerotic lesions. Plaques that are vulnerable to rupture demonstrate distinct histological characteristics, including large plaque and necrotic core volumes, extensive remodeling of the vessel at the lesion site, and attenuated fibrous caps. Precise metrics of typical vulnerable atherosclerotic plaque dimensions will need to be defined to facilitate their identification by noninvasive imaging modalities.

Key Points

  • Atherosclerotic plaque rupture is responsible for two-thirds of all acute coronary events

  • Although plaques vulnerable to rupture are characteristically large and contain big necrotic cores, they may not necessarily impinge on the coronary lumen because of expansive vascular remodeling

  • Unstable plaques are covered by substantially attenuated fibrous caps, and, hence, are called 'thin-cap fibroatheromas'; thin fibrous caps are severely inflamed

  • Proliferation of the vasa vasorum, plaque neovascularization, leakage of red blood cells in plaque, and intraplaque hemorrhage contribute to necrotic core enlargement

  • CT angiography can help identify morphological characteristics of vulnerable plaques, and PET imaging of fluorine-18-labeled fluorodeoxyglucose uptake might enable detection of plaque inflammation

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Figure 1: Histopathologic determinants of plaque vulnerability.
Figure 2: Multidetector CT characteristics of the unstable plaques of two patients who presented with acute coronary events.
Figure 3: Multidetector CT angiography in a 56-year-old hypertensive and overweight man with no other major risk factors.
Figure 4: Molecular imaging of plaque inflammation.

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Author information

Authors and Affiliations

  1. J Narula is Professor of Medicine and Chief of the Division of Cardiology and P Garg is Visiting Scientist at the University of California Irvine School of Medicine, Irvine, CA,

    Jagat Narula & Pankaj Garg

  2. S Achenbach is Professor of Cardiology at the University of Erlangen, Erlangen, Germany,

    Stephan Achenbach

  3. S Motoyama is Assistant Professor of Cardiology at Fujita University of Health Sciences, Japan,

    Sadako Motoyama

  4. R Virmani is the Director of the Cardiovascular Pathology Institute, Gaithersburg, MD,

    Renu Virmani

  5. HW Strauss is Professor of Radiology at the Memorial Sloan–Kettering Cancer Center, New York, NY, USA.,

    H William Strauss

Authors
  1. Jagat Narula
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  2. Pankaj Garg
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  3. Stephan Achenbach
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  4. Sadako Motoyama
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  5. Renu Virmani
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  6. H William Strauss
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Corresponding author

Correspondence to Jagat Narula.

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The authors declare no competing financial interests.

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Morphologic characteristics of vulnerable plaques. (DOC 248 kb)

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Narula, J., Garg, P., Achenbach, S. et al. Arithmetic of vulnerable plaques for noninvasive imaging. Nat Rev Cardiol 5 (Suppl 2), S2–S10 (2008). https://doi.org/10.1038/ncpcardio1247

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