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Predictors of Plaque Erosion in STEMI Patients
Study Questions:
What are the in vivo predictors of plaque erosion in patients with ST-segment elevation myocardial infarction (STEMI)?
Methods:
The investigators conducted a prospective study of 822 STEMI patients who underwent preintervention optical coherence tomography (OCT). Based on established OCT diagnostic criteria, plaque erosion was identified by 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. The association between plaque erosion and clinical, angiographical, and anatomical characteristics was assessed using a multivariable logistic regression model.
Results:
Using established diagnostic criteria, 209 had plaque erosion (25.4%) and 564 had plaque rupture (68.6%). Plaque erosion was more frequent in women <50 years when compared with those ≥50 years of age (p = 0.009). There was a similar, but less striking trend in men (p = 0.011). Patients with plaque erosion were more frequently current smokers, but had fewer other coronary risk factors (dyslipidemia, hypertension, chronic kidney disease, and diabetes mellitus) than those with plaque rupture. There was a preponderance of plaque erosion in the left anterior descending artery (LAD; 61.2%), whereas plaque rupture was more equally distributed in both the LAD (47.0%) and right coronary artery (43.3%). Despite the similar spatial distribution of erosions and ruptures over the lengths of the coronary arteries, plaque erosion occurred more frequently near a bifurcation (p < 0.001). In the multivariable analysis, age <50 years, current smoking, absence of other coronary risk factors, lack of multivessel disease, reduced lesion severity, larger vessel size, and nearby bifurcation were significantly associated with plaque erosion. Nearby bifurcation and current smoking were especially notable in men, while age <50 years was most predictive in women.
Conclusions:
The authors concluded that plaque erosion was a predictable clinical entity distinct from plaque rupture in STEMI patients, and a gender-specific role of risk factors in plaque erosion should be considered.
Perspective:
This study reports that plaque erosion tended to occur in younger patients, especially in premenopausal women with age <50 years. Current smoking was the predominant coronary risk factor of plaque erosion rather than dyslipidemia, hypertension, chronic kidney disease, or diabetes mellitus, and plaque erosion was most frequently located in the LAD with a limited focal distribution similar to plaque rupture, as well as proximity to a bifurcation. These findings may help better target coronary risk factor modification, and tailor management to optimize outcomes in patients with plaque erosion.
Keywords: Acute Coronary Syndrome, Calcification, Physiologic, Diabetes Mellitus, Dyslipidemias, Hypertension, Lipids, Myocardial Infarction, Plaque, Atherosclerotic, Primary Prevention, Renal Insufficiency, Chronic, Risk Factors, Smoking, Thrombosis, Tomography, Optical Coherence
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