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(Circulation. 1998;97:26-33.)
© 1998 American Heart Association, Inc.

Clinical Investigation and Reports

Coronary Angioscopic Findings in the Infarct-Related Vessel Within 1 Month of Acute Myocardial Infarction

Natural History and the Effect of Thrombolysis

Eric Van Belle, MD, PhD; Jean-Marc Lablanche, MD; Christophe Bauters, MD; Nathalie Renaud, MD; Eugène P. McFadden, MRCPI; ; Michel E. Bertrand, MD

From Service de Cardiologie B et Hémodynamique, Hôpital Cardiologique, Lille Cedex, France.

Correspondence to M.E. Bertrand, MD, Service de Cardiologie B, Hôpital Cardiologique, Boulevard du Professeur J Leclercq, 59037 Lille Cedex, France. E-mail bertrandme{at}aol.com

	Abstract

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Background—Limited angioscopic information is available on the natural history of infarct-related plaque after myocardial infarction (MI), in particular the effect of thrombolysis.

Methods and Results—We studied with angioscopy the morphological characteristics of the infarct-related lesion in 56 patients between 24 hours and 4 weeks after MI. Forty of these patients were initially treated with a thrombolytic agent. Most lesions were complex (complex+ulcerated shape=54%). The predominant color of the plaque was yellow in 79% of cases; only 6% were uniformly white. Angioscopically visible thrombus was found in 77% of cases. Despite angioscopic evidence of instability, only 7% of the patients had post-MI angina. During the 1-month time window since the occurrence of MI, there was no significant difference in the angioscopic appearance of the plaque except for a slight increase in uniformly white plaques (P=.07). The use of a thrombolytic agent at the onset of MI was associated with a reduction in thrombus size and less protruding thrombi (P=.02) but not with a decreased frequency of plaque containing thrombi. Furthermore, a trend for more frequently ulcerated plaques (45% versus 16%, P=.06) was associated with the use of a thrombolytic agent.

Conclusions—These results suggest that healing of the infarct-related lesion requires more than 1 month and that an "unstable" yellow plaque with adherent thrombus is common during that period. This finding may partly explain the unique behavior of recent infarct-related lesions, which are more prone to occlude than other lesions.

Key Words: myocardial infarction • thrombolysis • angioplasty

	Introduction

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Recent infarct-related lesions show a high propensity for reocclusion. In patients treated with thrombolytic agents who have a patent infarct-related artery at 48 hours, reocclusion occurs in the ensuing 3 months in almost 30%.^{1 2} Furthermore, after successful percutaneous transluminal coronary angioplasty (PTCA) of the culprit lesion in the month after myocardial infarction (MI), the restenosis (51%) and occlusion (13%) rates at 6-month follow-up are excessively high.³ The reason(s) for the high incidence of late vessel reocclusion after MI are unclear.

Coronary angioscopy provides direct visualization of the intravascular lumen and permits a complete description of plaque surface. This technique has been validated by the results of histopathology⁴ and provides information that cannot be obtained by angiography⁵ on plaque shape and color and on the presence and the size of thrombi. To date, several authors have described the angioscopic characteristics of the infarct-related lesions early after MI.^{6 7 8 9} Few data are available,^{8 10} however, on the appearance and characteristics of the plaque during the subsequent weeks, the time window within which most such occlusions occur. In addition, while the effect of thrombolysis on the angiographic morphology of the infarct-related lesion is well characterized,^{11 12} there are few angioscopic data. Indeed in the only published series that used angioscopy to investigate the effect of thrombolysis on plaque morphology, thrombolysis was not specifically performed for acute MI but to study its effects on intracoronary thrombus identified on angioscopy.⁹

The purpose of the study was (1) to describe the morphological characteristics of the infarct-related lesion within 1 month of MI in a large population of patients initially treated by thrombolysis or conservative medical management; (2) to describe the natural history of such lesions as a function of elapsed time in the month after MI; and (3) to evaluate the effect of thrombolytic therapy on the angioscopic characteristics of the infarct-related lesion.

	Methods

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Patient Population
It is our institutional policy to perform coronary angiography in all patients with recent MI in the absence of absolute contraindications; ad hoc angioplasty of the infarct-related vessel is performed, provided that the diameter stenosis is >50% and that the overall anatomy of the coronary vessels does not preclude angioplasty, for example, left main disease or lesions judged to be unsuitable for angioplasty by the operator.³

During the time period of the study (January 1992 to June 1994), 592 patients underwent PTCA of an infarct-related lesion between 24 hours and 4 weeks after acute MI. All patients were considered potential candidates for angioscopy, and the procedure was performed if the following criteria were met: (1) patients had MI between 24 hours and 4 weeks before angiography; (2) the infarct-related artery; determined from the entry ECG, ventriculographic contraction abnormalities, and coronary angiography findings; was clearly identifiable; (3) percutaneous or surgical revascularization was not attempted before coronary angioscopy; (4) the infarct-related lesion was anatomically suitable for angioscopy (see below); and (5) angioscopy equipment and staff skilled in angioscopy were available at the time of PTCA. The protocol was approved by the Institutional Review Board of our institution and informed consent was obtained from all patients before angioscopy.

Thus angioscopy of the infarct-related lesion was performed in 56 patients between 24 hours and 4 weeks after an acute MI and before any mechanical revascularization procedure (angioplasty or coronary artery bypass grafting). For the purpose of the study, patients were classified depending on whether or not they had received thrombolytic therapy at the time of MI. They were also classified as a function of the time elapsed between the MI and the angioscopy procedure into early-recent MI (24 hours to day 10) and late-recent MI(day 11 to day 30).

Angioscopy Procedure and Analysis
To be considered anatomically suitable for coronary angioscopy, a lesion had to meet the following criteria: (1) the culprit lesion was located more than 1.0 cm from the ostia to allow inflation of the occlusion cuff, (2) the luminal diameter of the coronary artery was >2.0 mm and <4.0 mm, (3) the segment of the artery proximal to the lesion was not tortuous and had no significant angulation, and (4) the site of cuff inflation was not the site of a major side branch. The above criteria were designed to ensure the safety of the procedure and to ensure a coaxial position of the angioscope in order to optimize image acquisition.

Coronary angioscopy was performed with the ImageCath system (Baxter, Edwards LIS Division), which includes an angioscope catheter, an irrigation system, a light source, and a video system.¹³ Aspirin (500 mg IV) was given 2 hours before the procedure. After administration of 10{ths}000 IU of heparin, the lesion was crossed with a standard 0.014-in floppy guidewire. The angioscopy catheter was then advanced over the guidewire and an initial recording was obtained while the angioscope was advanced through the lesion; subsequently, another recording was obtained while the angioscope was withdrawn. The guidewire was left in place and the angioscopy catheter was then exchanged for a standard PTCA catheter.

All videotapes were reviewed jointly by two physicians who were unaware of the angiographic findings. The definitions and classifications used (Table 3) are adapted from the "simplified Ermenonville classification" that was proposed by the European Working Group on Coronary Angioscopy.¹⁴

View this table: [in this window] [in a new window]   Table 3. Angioscopic Variables

The angioscopic evaluation of the plaque before PTCA consisted of an assessment of the shape of the narrowing, plaque color, and presence of thrombus. The shape of narrowing was classified as smooth concentric, smooth eccentric, complex, or ulcerated; a lesion was classified as smooth eccentric if a segment of normal-appearing wall was visualized at the site of the lesion; a complex narrowing was defined as an irregular plaque with jagged edges; an ulcerated plaque was defined as an area of lining red clot surrounded by irregular plaque. The color of the plaque was classified as white or yellow. The "predominant" color was defined as the color that made up >50% of the plaque surface seen on angioscopy. The "darkest" color was defined as the darkest zone seen in any part of the plaque. Angioscopic thrombus (Figure ) was defined as a superficial (lining) intraluminal, or protruding mass, adherent to the vessel surface but clearly identified as a separate structure. Thrombus was further classified by color (white, red, or mixed red and white). A "pure" white thrombus was defined as a shaggy, irregular, and cotton-wool–like mass.

View larger version (23K): [in this window] [in a new window]   Figure 1. Coronary angioscopic findings A, Yellow plaque (P) with a lining thrombus (T). B, Yellow plaque (P) with a large protruding thrombus (T). C, Predominantly white plaque (P) with a localized yellow area (arrow) and an adjacent lining thrombus (T). L indicates lumen.

Angiographic Analysis
Two experienced interventional cardiologists performed the qualitative analysis independently. Disagreements were resolved by a further joint reading. Lesions were classified as concentric or eccentric. Location (bifurcation), length (>10 mm), presence of calcification, and irregular edges were also noted. Angiographic criteria of intracoronary thrombus were recorded as previously described:^{15 16 17} (1) an intraluminal filling defect surrounded by contrast material, seen in multiple projections; (2) unilateral or bilateral overhanging edges of the lesion; (3) haziness; and (4) ulcerated borders. The anterograde blood flow before angioplasty was graded with the TIMI Study Group classification.¹⁸

Quantitative computer-assisted angiographic measurements of the lesion were performed on end-diastolic frames by a single investigator unaware of the angioscopic findings with the CAESAR (Computer Assisted Evaluation of Stenosis And Restenosis) system.¹⁹ We routinely perform angiography in at least two projections, after intracoronary injection of isosorbide dinitrate (2 mg). Reference diameter and minimal luminal diameter were measured and percent stenosis was calculated for each lesion. Total occlusion was defined as a TIMI grade 1.

Statistical Analysis
Data are presented as mean value±SD. Differences between means were assessed using unpaired Student's t test or ANOVA followed by Scheffe's F test when applicable. Differences between proportions were assessed by chi-square analysis or Fisher's exact test when applicable. A value of P<.05 was considered to indicate statistical significance.

	Results

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The baseline characteristics of the study population are detailed in Table 1. Most patients were men. Mean age was 55±11 years. A thrombolytic agent was used in two thirds of the patients at the time of acute MI; 98% of patients were treated with oral aspirin (100 to 300 mg/daily) from admission and 100% of patients were treated with heparin infusion to achieve a target activated clotting time for at least 72 hours after MI. Seven percent of the population had post-MI unstable angina. The mean interval between MI and angioscopy was 12.2±5.8 days. The culprit lesion was located in the left anterior descending (50%), right coronary (34%), and left circumflex artery (16%), respectively.

View this table: [in this window] [in a new window]   Table 1. Clinical Characteristics of the Study Population

The angiographic characteristics of the infarct-related lesion are summarized in Table 2. Lesions were eccentric in 41% and ulcerated in 21% of the cases. The presence of thrombus was suspected in 12% of the cases, using the most strict angiographic definition (thrombus=filling defect), and in 54% of the cases when we used a combination of classic criteria (see details in Table 2).^{15 16 17} The mean reference diameter of the culprit vessel was 3.1 mm, the minimal luminal diameter at the lesion site was 0.71 mm, and the mean percent stenosis was 76%. The artery was open in 79% of the cases (TIMI=3) and totally occluded in 14% (percent stenosis=100, TIMI=0 or 1).

View this table: [in this window] [in a new window]   Table 2. Angiographic Variables

The angioscopic characteristics of the lesions are summarized in Table 3, and typical findings are shown in the Figure. A majority of lesions were complex (complex+ulcerated shape). The predominant color of the plaque was yellow in 79% of the cases. Fifteen percent were predominantly white with some yellow plaque (Figure); only 6% of the plaques were uniformly white (darkest color=white). Seventy-seven percent of the patients had angioscopically visible thrombus at the infarct-related lesion. Lining thrombi were more frequent than protruding thrombi; thrombus color was mixed in 55% of cases; and a cotton-wool–like thrombus was observed in 18% of the patients.

Angioscopic Variables According to the Time Elapsed Since MI
To analyze the relationship between the angioscopic variables and the time elapsed between the MI and the angioscopic procedure, patients were first divided into two groups as a function of the median delay between MI and angioscopy (10 days): early-recent MI (day 1 to 10) and late-recent MI (day 11 to 30). The plaque shape (complex+ulcerated shape=46% versus 65%) did not differ between groups. The predominant color of the plaque was similar in the two groups (yellow=76% versus 81%): however, a trend toward a higher frequency of uniformly white plaques (0% versus 12%, P=.07) was observed in late-recent MI. The presence (79% versus 75%) and the size (protruding thrombi=36% versus 43%) of thrombi did not differ significantly between patients studied before or after day 10. Furthermore, there was no difference in the color of the thrombus (white, red, and mixed) between patients studied before or after day 10. Similar results were obtained when the population was divided into quartiles and tested for trends (Table 4).

View this table: [in this window] [in a new window]   Table 4. Relation of Angioscopic Characteristics to the Time Elapsed Between Myocardial Infarction and Angioscopy

Angioscopic Variables According to the Use of a Thrombolytic Agent at the Time of MI
The relationship between the angioscopic variables and the prior administration of a thrombolytic agent at the time of myocardial infarction is presented in Table 5. A trend for more complex+ulcerated plaques was observed in patients treated with thrombolysis (complex+ulcerated plaques=61% versus 38%, P=.16). The apparently higher proportion of complex plaques in patients treated with thrombolytic therapy was mainly due to a higher proportion of ulcerated plaques (ulcerated plaques=45% versus 15%, P=.06). The dominant color of the plaque was similar in the two groups (yellow=69% versus 82%), however a higher frequency of completely white plaques (0% versus 12%, P=.01) was observed in patients who had not received thrombolytic therapy. The prevalence of thrombus was slightly, but not significantly, higher in patients who had received thrombolytic therapy compared with those who had not (82% versus 63%, P=.12). However, the size of the observed thrombus was significantly smaller in patients who had received thrombolytic therapy (protruding thrombus=30% versus 70%, P=.02). No difference in the color of the thrombus (white, red, or mixed) was detected.

View this table: [in this window] [in a new window]   Table 5. Relation Between Angioscopic Characteristics and the Prior Administration of Thrombolytic Therapy

Diagnostic Value of Angiographic Criteria for Intracoronary Thrombi
In this study, an evaluation of the diagnostic value of angiography for the detection of intracoronary thrombi within 1 month after MI was performed with the use of classic angiographic criteria (see "Methods" and Table 6). Using the presence of a "filling defect" as the only criterion, the specificity and positive predictive value of angiography were very high (specificity=100%; positive predictive value=100%). However, the sensitivity and negative predictive value were very low (sensitivity=16%; negative predictive value=27%). With the use of a combination of four criteria (filling defect, overhanging edges, haziness, ulcerated borders) the specificity and positive predictive value of angiography were slightly decreased (specificity=85%; positive predictive value=93%). However, the sensitivity and negative predictive value were much higher (sensitivity=65%; negative predictive value=58%).

View this table: [in this window] [in a new window]   Table 6. Diagnostic Value of Angiographic Criteria for the Detection of Intracoronary Thrombus

	Discussion

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The recent infarct-related lesion has a high propensity for spontaneous reocclusion in the weeks or months after thrombolysis.^{1 2} Even when successfully treated by balloon angioplasty, this propensity for reocclusion persists.³ Occlusion of the infarct-related vessel has a well-documented detrimental effect on left ventricular function in the short term.^{3 20} Furthermore, an occluded infarct-related vessel has a detrimental effect on left ventricular remodeling and survival in the long term.^{21 22} Angiographic studies in patients with recent infarction have not identified specific morphological characteristics of the plaque that have a high predictive value for reocclusion.^{23 24 25}

The results of the present study demonstrate that angioscopic characteristics of plaque instability (complex morphology, yellow color, thrombus) last during 1 month after MI, even in asymptomatic patients and in patients initially treated with thrombolysis. These findings provide a possible explanation for the unique behavior of the infarct-related lesions that are more prone to late occlusion than other lesions. In the era of new and very potent antiplatelet therapies, and with expanding indications for coronary stenting, these findings have potential implications for the clinical management of patients after MI.

The Present Study and Its Relation to Previous Studies
The three important characteristics of the infarct-related lesion observed within the first month of MI are thrombus (77%), yellow plaque (79%), and complex morphology (54%), that is, morphological aspects associated with plaque instability.^{7 26} Within that period, these findings are not dependent on the time elapsed since infarction, as demonstrated by the lack of difference between the patients studied before day 10 and those studied between day 11 and day 30 after MI. A previous report by Mizuno et al⁷ suggests that when angioscopy is performed in "old" MI (the mean time between MI and angioscopy was more than 2 months) the plaque is usually healed with 82% of white plaques and 0% of thrombus. The same authors showed that when angioscopy is performed within hours or days after the onset of MI there is a high frequency of yellow plaque and thrombus^{6 7} ; these observations were independently reported by others.^{8 9} The results of the present study suggest that the healing process of the infarct-related plaque requires more than 1 month. This extends the findings of Ueda et al⁸ in a small series (10 patients) investigated 1 month after MI. They found yellow plaque in all patients, thrombus in 6 patients (60%), and intimal flap in 4 patients (40%). The population studied was highly selected, as most (n=7) had a combination of mechanical reperfusion and thrombolysis. The results of our study extend their findings to a much larger population of patients that is additionally more representative of the general patient population after MI.

It is important to emphasize that the results of the present study, as well as the results of Ueda et al,⁸ are significantly different from those reported by Tabata et al¹⁰ in a group of patients who underwent angioscopy at a mean interval of 2 weeks after MI. In this study only 50% of the patients had yellow plaques and only 43% had lesions containing thrombi. A possible explanation for the apparent discrepancy relates to the high proportion of patients in their study in whom revascularization was achieved by mechanical means alone (34%); by contrast, this was the case in only 9% of patients in the study by Ueda et al and in none of the patients in our study.

Angioscopic Findings: Relation to Symptoms
Angioscopic characteristics of plaque instability, yellow plaque, and plaque containing thrombus, are frequently associated with clinical instability in patients without recent MI.^{7 26} After MI, our results show that angioscopic findings suggestive of plaque instability are extremely frequent (75% to 80% of the study population) even in the absence of clinical symptoms. Reported rates of early post-MI unstable angina range from 6% to 21% of patients^{27 28 29} (7% in the present study). Thus after MI, clinical status is a poor predictor of plaque stability.

These results are significantly different from those of Tabata et al,¹⁰ who found that thrombus, identified by angioscopy, was highly predictive of clinical instability. As already discussed, the population studied by Tabata et al was significantly different from the population in the present study in that a high proportion of patients were initially treated with balloon angioplasty (34%); in addition, the clinical presentation at the onset of MI was more frequently a non–Q-wave MI (10%), and a significantly higher proportion of patients had post-MI unstable angina (33%).

Effect of Thrombolysis on Plaque Morphology and Thrombus Burden
The use of thrombolytic agents had a significant impact on the thrombotic burden; only 30% of patients treated by thrombolytic therapy had protruding thrombi versus 70% of patients who had not received thrombolytic therapy (P=.02). However, thrombolytic therapy did not reduce the prevalence of thrombus as demonstrated by the fact that thrombus was equally frequent in both groups (Table 5).

The use of thrombolysis was associated with a slightly higher prevalence of ulcerated plaques (P=.17). Similarly, the percentage of uniformly white plaques, a marker of plaque stabilization, was lower in patients treated with thrombolysis (P=.01; Table 5). These effects of thrombolysis probably reflect the fact that clot lysis exposes an underlying ulcerated lesion.

These data provide new insights into residual plaque morphology after thrombolysis for acute MI. They demonstrate that thrombolysis is associated with a reduction in thrombus mass but that, perhaps surprisingly, morphological characteristics of plaque instability last for several weeks and are even more frequent in patients treated with thrombolytic agents.

Angiographic Versus Angioscopic Identification of Thrombus in Recent MI
Several studies have evaluated the diagnostic value of angiography compared with angioscopy in the detection of thrombus.^{5 26} However, these studies used a very strict definition, the filling defect, as the angiographic criterion for the presence of intracoronary thrombus. Furthermore, none of these studies investigated patients with recent MI. In the present report, the sensitivity of the angiographic "filling defect" for the detection of intra coronary thrombus was 16%, consistent with the 19% to 27% sensitivity reported in the two series referred to above.^{5 26} However, using a combination of angiographic criteria previously associated with intracoronary thrombus (filling defect, overhanging edge, haziness, ulcerated borders),^{15 16 17} 65% of thrombi were suspected by angiography. While these results confirm that angiography has a lower sensitivity than angioscopy, they show also that careful analysis of the angiographic pattern can detect two thirds of the thrombi observed by angioscopy. This compares favorably with previously published data.^{5 26}

Therapeutic Implications of the Presence of Thrombus in Recent MI
Delayed PTCA of the culprit lesion in patients with a recent MI initially treated by thrombolysis is a strategy associated with a satisfactory clinical outcome.³ However, when such a procedure is performed, the restenosis (51%) and occlusion (13%) rates at 6-month follow-up³ are higher than those reported for elective PTCA. Moreover, the latter complication is usually associated with a deleterious effect on ejection fraction.³ The results of the present study together with those of a previous report, demonstrating that the presence and the size of thrombus at the angioplasty site are strong predictors of restenosis and reocclusion at 6 months,¹³ suggest that the high frequency of "silent" thrombus in the infarct-related lesion, even after thrombolysis, may contribute to the worse 6-month angiographic outcome when angioplasty is performed in this clinical setting. The results of the present study need also to be interpreted in the light of previous results by White et al²⁶ and by Feld et al⁹ demonstrating that the presence of thrombus at the angioplasty site, as seen by angioscopy, is associated with a less favorable early²⁶ and late⁹ clinical outcome.

These results are also consistent with the observation that the initial success of thrombolysis for acute MI, as documented by vessel patency at angiography at 48 hours, is countered by reocclusion within 3 months in almost 30% of patients.^{1 2} Indeed the high rate of reocclusion in this setting is associated with deleterious effects on both left ventricular ejection fraction²⁰ and on clinical outcome.²²

Study Limitations
Some study limitations need to be acknowledged. First, the fact that all patients investigated underwent PTCA after angioscopy raises the possibility of selection bias. However, the fact that during the study period all patients in our institution undergoing coronary angiography after a recent MI had ad hoc angioplasty if lesion location and morphology was suitable suggests that the population studied was representative of the overall population of post-MI patients in our institution.³ This is further corroborated by the relatively low rates of "filling defect" seen at angiography (12%) and post-MI angina (7%) in the present study. These rates are in the lower range of those previously described in the general population of patients with MI when studied during a similar period of time.^{11 27 28 29} Second, since angioscopic analysis was performed jointly by two physicians, data on interobserver and intraobserver variability are not available. However, the inherently subjective nature of angioscopy was minimized by the use of a classification adapted from the "simplified Ermenonville classification."¹⁴

Conclusions
This study suggests that the healing process of the infarct-related lesion requires more than 1 month and that an "unstable" yellow plaque with adherent thrombus and complex morphology is a common finding during that period irrespective of the clinical picture. In addition, thrombolytic therapy, despite its documented beneficial effects on clinical outcome, has a less dramatic effect on plaque stabilization. The persistence of plaque instability, even in the absence of symptoms, provides a possible explanation for the previously described higher rates of restenosis and reocclusion when angioplasty is performed at recent infarct-related lesions as well as the high rate of late vessel occlusion after successful thrombolysis. In the era of new and very potent antiplatelet agents and in the light of recent progress in the field of coronary stenting, these findings suggest that the use of such approaches could be useful in improving the outcome of patients after MI.

Received June 19, 1997; revision received September 5, 1997; accepted September 25, 1997.

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