Culprit Lesion Remodeling and Long-term (> 5years) Prognosis in Patients with Acute Coronary Syndrome Hiroyuki Okura*, MD; Nobuya Matsushita**,MD Kenji Shimeno**, MD; Hiroyuki Yamaghishi**, MD Iku Toda**, MD and Kiyoshi Yoshida, MD* *, Kurashiki, Japan **Bell Land General Hosp, Sakai, Japan
DECLARATION OF CONFLICT OF INTEREST Hiroyuki Okura, MD Nobuya Matsushita,MD Kenji Shimeno, MD Hiroyuki Yamaghishi, MD Iku Toda, MD Kiyoshi Yoshida, MD Nothing to disclose Nothing to disclose Nothing to disclose Nothing to disclose Nothing to disclose Nothing to disclose
Background Positive arterial remodeling () is recognized as one of the morphological features of the vulnerable plaque. Shchoenhagen P, Nissen SE et al. Circulation 2000;101:598-603
Positive remodeling and acute coronary syndrome (ACS) Reference EEM CSA < Target-lesion EEM CSA 60 50 p=0.001 40 30 Unstable Stable 20 10 0 Positive Remodeling Absence of Remodeling Negative Remodeling Proximal ref. Lesion Distal ref. Shchoenhagen P, Nissen SE et al. Circulation 2000;101:598-603
Positive remodeling and thinning of fibrous cap fibrous cap thickness (μm) thickening thinning 150 100 50 0-50 -100-150 r = -0.65, p < 0.0001-10 -7.5-5 -2.5 0 2.5 5 7.5 10 negative remodeling EEM CSA (mm 2 ) Yamada, R, Okura H et al. Circ Cardiovasc Interv 2010;3:484-490 positive remodeling
Background Although previous intravascular ultrasound (IVUS) studies have shown that is related to restenosis and revascularization after bare-metal stent (BMS) implantation, its long-term prognostic impact is still unknown. Okura H, Fitzgerald PJ et al. J Am Coll Cardiol 2001;37:1031-5 Okura H et al. Heart 2007;93:1219-25. Okura H, Fitzgerald PJ, Mintz GS et al. Am J Cardiol 2009;103:791-5
Objective The purpose of this study was to investigate the longterm impact of culprit lesion arterial remodeling on prognosis in patients with ACS.
Study population A total of 134 ACS patients with pre- and post-intervention IVUS Acute myocardial infarction: 103 patients Unstable angina: 31 patients Okura H et al. Heart 2007;93:1219-25.
IVUS Imaging protocol Mechanical ultrasound system (Boston Scientific Corporation) with 40 MHz transducer. Automated pullback (0.5 mm/sec) External elastic membrane (EEM), plaque plus media (P+M) and lumen cross sectional areas (CSA), minimal stent area (MSA). EEM CSA Lumen CSA P+M CSA MSA Mintz GS, et al. J Am Coll Cardiol. 2001;37:1478-92
Positive remodeling () Intermediate / negative remodeling (IR/NR) Proximal ref. EEM CSA < Lesion EEM CSA Proximal ref. EEM CSA Lesion EEM CSA Proximal Ref. Lesion Distal Ref. Proximal Ref. Lesion Distal Ref. Okura H et al. Heart 2007;93:1219-25.
End point Major adverse cardiac events (MACE) : All-cause death, ACS and target lesion revascularization (TLR) Follow-up period 5.8 years (median)
Clinical and lesion characteristics Age (y) Male gender (%) Risk factors (%) Hypertension Diabetes Hyperlipidemia Smoking Family history Target vessel LAD / LCX / RCA (n=83) 63.0 8.0 66 (78 %) 42 (46 %) 38 (46 %) 41 (49 %) 29 (39 %) 7 ( 8 %) 45 / 12 /27 IR/NR (n=51) 64.2 7.2 39 (76 %) 21 (41 %) 15 (29 %) 24 (42 %) 31 (47 %) 5 (10 %) 39/ 6 / 6 p NS NS NS 0.07 NS NS NS *LAD = left anterior descending artery, LCX = left circumflex artery, RCA = right coronary artery. NS
Baseline QCA results (n=83) IR/NR (n=51) p Pre-intervention Reference, mm 2.8 0.4 MLD, mm 0.3 0.2 %DS, % 87 12 Lesion length, mm 9.9 3.6 Post-intervention Reference, mm 3.2 0.4 MLD, mm 2.8 0.5 %DS, % 12 8 MLD = minimal lumen diameter, DS = diameter stenosis 2.8 0.3 NS 0.3 0.4 NS 86 15 NS 9.8 4.6 NS 3.1 0.3 NS 2.8 0.4 NS 11 6 NS
Baseline IVUS results (1) IR/NR p (n=83) (n=51) Target Lesion EEM CSA (pre), mm 2 18.6 6.0 14.5 4.5 0.002 P+M CSA (pre), mm 2 16.2 5.8 12.4 4.5 0.003 Lumen CSA (pre), mm 2 2.2 0.4 2.1 0.6 NS MSA (post), mm 2 8.1 2.5 8.0 2.6 NS Proximal Reference EEM CSA, mm 2 15.7 4.3 17.5 5.4 NS P+M CSA, mm 2 8.7 2.6 8.9 3.0 NS Lumen CSA, mm 2 7.0 2.5 8.6 3.8 0.02 Distal Reference EEM CSA, mm 2 12.9 4.6 12.3 3.9 NS P+M CSA, mm 2 6.3 3.1 5.9 2.6 NS Lumen CSA, mm 2 6.3 2.8 6.3 2.2 NS
Baseline IVUS results (2) IR/NR p (n=83) (n=51) Pre-intervention Plaque type NS Fibrous 50 (60) 27 (53) Fibrofatty 28 (40) 17 (34) Calcified 5 ( 6) 7 (13) Thrombus 29 (35) 16 (31) NS Plaque rupture 22 (27) 11 (22) NS All, n (%)
Clinical Events (n=83) IR/NR (n=51) p All-cause death 9 (10.8) 1 (2) 0.058 Cardiac death 7 (8.4) 1 (2) 0.125 Non-cardiac death 2 (2.4) 0 (0) 0.264 ACS 11 (13.3) 3 (5.9) 0.176 STEMI 6 (7.2) 2 (3.9) NSTEMI 2 (2.4) 0 (0) Unstable AP 4 (4.8) 1 (2) TLR 28 (33.7) 7 (13.7) 0.01 PCI 26 (92.9) 6 (85.7) CABG 2 ( 7.1) 1 (14.3) All-cause death + ACS 17 (20.5) 4 (7.8) 0.051 MACE 37 (44.6) 10 (19.6) 0.003 All, n (%)
MACE-free survival MACE-free survival 1.8.6.4.2 0 Log-rank P = 0.0037 IR/NR 0 1 2 3 4 5 6 7 8 9 (years) MACE = All-cause death, ACS and TLR
Survival Survival 1.8.6 IR/NR.4.2 0 Log-rank P = 0.043 0 1 2 3 4 5 6 7 8 9 (years)
ACS-free survival ACS-free survival 1.8.6 IR/NR.4.2 0 Log-rank P = 0.039 0 1 2 3 4 5 6 7 8 9 (years)
Predictors of MACE Univariable Multivariable p value Chi-square OR (95% CI) p value 0.03 5.77 2.39 (1.17-4.88) 0.02 Diabetes 0.01 4.79 1.93 (1.07-3.49) 0.03
Case Example : 35 M with Pre Lcx Post MSA=9.0 mm 2 Distal Ref. Lesion Proximal Ref.
Case Example : 37 M 17 months later 99%
Case Example : 43 M 6 years later 99% 99% 90% RCA LAD LCX
Conclusions Despite successful revascularization, target lesion was associated with long-term prognosis in patients with ACS. may be a marker of vulnerable patients.
Causes of death Age (years) Gender Remodeling Follow-up period (days) Cardiac or noncardiac death Cause of death 78 Male IR/NR 25 Cardiac Cardiogenic shock 70 Female 0 Cardiac Cardiogenic shock 67 Female 9 Cardiac Congestive heart failure 74 Female 128 Cardiac Congestive heart failure 59 Male 442 Cardiac Sudden cardiac death 48 Male 728 Cardiac Sudden cardiac death 74 Male 1,252 Non-cardiac Gastrointestinal bleeding 80 Male 1,368 Cardiac Congestive heart failure 70 Male 2,598 Non-cardiac Stroke 47 Male 2,885 Cardiac Sudden cardiac death