Multiple Ruptured Plaques
Serial Intravascular Ultrasound Examinations
A 78-year-old man with a history of hypertension, hypercholesterolemia, and diabetes mellitus presented with acute anterior myocardial infarction in November 2002. Coronary angiography revealed total occlusions of the mid-left anterior descending coronary artery (LAD) and the right coronary artery, as well as ulcerations in the proximal LAD (Figure 1A). Coronary stenting was performed after predilatation. The final angiogram showed a good result (Figure 1B). Intravascular ultrasound (IVUS) imaging using a 40-MHz transducer (SCIMD/Boston Scientific Corporation) demonstrated not only optimal stent expansion, but also ruptured plaques in the proximal LAD and the mid-LAD proximal to the stented segment (Figures 2 and 3⇓, top). Aspirin (81 mg daily), ticlopidine (100 mg twice daily), and an HMG-CoA reductase inhibitor were prescribed.
In April 2003, follow-up angiography demonstrated haziness at the ostium of the LAD and ulcerations in the proximal LAD, although in-stent restenosis was not observed (Figure 1C). IVUS revealed unhealed or rather extended plaque ruptures and positive remodeling (an increase in external elastic membrane cross-sectional area) in the proximal and mid-LAD (Figures 2 and 3⇑, bottom). C-reactive protein measured 14 mg/L.
Plaque rupture or erosion with subsequent thrombus formation is the most frequent cause of acute coronary syndromes. Pathological studies, however, have reported healed ruptured plaques in cases of noncardiac death. In the present study, multiple ruptured plaques had not healed for 6 months; rather the cavity areas increased. Systemic inflammation might play an important role in the occurrence, unhealing, and extension of multiple plaque ruptures.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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