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Transcript of Final clickable pps for vp s ymposium @aha 2001
Association for Eradication of Heart Attack
www.VP.org
#1 killer of human
beings in the 21st century?
Fatal Heart Attack!
What causes heart attack?
Vulnerable Plaque
The short answer is:
What are vulnerable plaques?
Dangerous forms of atherosclerotic plaques
that can rupture or induce thrombosis and
lead to critical disruption of blood flow.
The short answer is:
Everybody has atherosclerosis, the question is who has vulnerable plaque
Sudden Cardiac DeathAcute MI
VulnerablePlaque(s)
Vulnerable Plaque and Vulnerable Patient, The Challenge of
Cardiovascular Medicine in 21st Century
An introductory tutorial from
VP.orgIn conjunction with
The Center for Vulnerable Plaque Research
University of Texas Houston and Texas Heart Institute
What Do We Know About Vulnerable Plaque?
Center for Vulnerable Plaque ResearchUniversity of Texas at Houston
Texas Heart InstituteOctober 2001
Morteza Naghavi, MDMohammad Madjid, MD Silvio Litovsky, MD Alireza Zarrabi, MDMaziar Azadpour, MD Parsa Mirhaji, MD Cornelius Nwora, MD
Ward Casscells, MD James Willerson, MD
Salute to Pioneers
Carl von Rokitansky (1804-1878)
Rokitansky gave early detailed descriptions of arterial disease. He
is alleged to have performed 30,000
autopsies.
Rokitansky in 1841 championed the Thrombogenic Theory. He proposed that the deposits observed in the inner layer of the arterial wall
derived primarily from fibrin and other blood elements rather than being the result of a purulent process. Subsequently, the atheroma resulted from the
degeneration of the fibrin and other blood proteins as a result of a preexisting crasis of the blood, and finally these deposits were modified toward a pulpy
mass containing cholesterol crystals and fatty globules. This theory came under attack by Virchow
First studies on inflammation of vessels, particularly phlebitis, Started at a time when Cruveilhier2had just stated: La phlebite domine toute la pathologie.3 First a great number of preparatory studies on fibrin, leukocytes, meta-morphosis of blood, published separately. …
Rudolf Virchow 1821-1902
The Father of Cellular Pathology
Virchow appreciates prior works.
Virchow presented his inflammatory theory. He utilized the name of "endarteritis deformans." By this he meant that the atheroma was a product of an inflammatory process within the intima with the fibrous thickening evolved as a consequence of a reactive fibrosis induced by proliferating connective tissue cells within the intima.
Olcott 1931 “plaque rupture”
Leary 1934 “rupture of atheromatous abscess”
Wartman 1938 “rupture-induced occlusion”
Horn 1940 “plaque fissure”
Helpern 1957 “plaque erosion”
Crawford 1961 “plaque thrombosis”
Gore 1963 “plaque ulceration”
Friedman 1964 “macrophage accumulation”
Byers 1964 “thrombogenic gruel”
Chapman 1966 “plaque rupture”
Plaque Fissure in Human Coronary Thrombosis (Abstract) Fed. Proc. 1964, 23, 443 Paris Constantinidis
“The destruction of the hyalinized wall separating lumen from the atheroma was almost always observed to be preceded by or associated with its invasion by lipid containing macrophages.”
Friedman and van den Bovenkamp 1965
Unheralded Pioneers
N Engl J Med 1999
“Atherosclerosis; an inflammatory disease”
Ross R.
Russell Ross
Atherosclerosis; arterial “Response to Injury”
N Engl J Med 1976 Aug 12;295(7):369-77 The pathogenesis of atherosclerosis (first of two parts).Ross R, Glomset JA.
James T. Willerson 1981N Engl J Med 1981 Mar 19;304(12):685-91
Plaque Thrombosis
Erling Falk Michael Davies
Autopsy Series
Thin Fibrous Cap + Large Lipid Core + Dense Macrophage
A culprit ruptured plaque
1981-1990
Plaque Rupture
Seymour GlagovCompensatory Enlargement of Human Atherosclerotic Coronary Arteries N Engl J Med 1987 May
28;316(22):1371-5
<50% stenosis
Luminal area is not endangered until more than 40% of internal elastic lamina is destructed and occupied by plaque
Coronary artery disease is a disease of arterial wall disease not lumen.
Positive Remodeling<80%
stenosis
Angiographic progression of coronary artery disease and the development of myocardial infarction.Ambrose JA, Tannenbaum MA, Alexopoulos D, Hjemdahl-Monsen CE, Leavy J, Weiss M, Borrico S, Gorlin R, Fuster V.
Department of Medicine, New York Cardiac Center, Mount Sinai Medical Center, New York 10029.
Simultaneously, Little et al, Haft et al reported that majority of culprit lesions are found on previously non-critical stenosis plaques.
Conclusion: “Myocardial infarction frequently develops from non-severe lesions.”
J Am Coll Cardiol 1988 Jul;12(1):56-62
Ambrose, Fuster, and colleagues
Angiographically Invisible Plaques
Falk E., Shak P.K., Fuster V. Circulation 1995
Non-stenotic (<75%) plaques cause about 80% of deadly MI
Macrophage- driven MMPs soften plaque cap and prompt it to rupture
P.K. Shah
Peter LibbyThe fate of
atherosclerosis and its thrombotic complication are governed by immune
system.
Goran Hanssonand others
Allard van der Wal
and others
•Eroded Plaque
Rupture-prone plaques are not the only type of vulnerable plaque
•Calcium Nodulevan der Wal - Netherlands
Renu Virmani -USA
Thiene - Italy
Kolodgie F., Burk A.P., Farb A., and Virmani R.
Muller JE, Abela GS, Nesto RW, Tofler GH.
Triggers, acute risk factors and vulnerable plaques: the lexicon of a new frontier.
J Am Coll Cardiol. 1994 Mar 1;23(3):809-13
James E. Muller 1994
Muller coined the term of “Vulnerable” Plaque
Muller likened Vulnerable Plaques to American nuclear missiles stored underground in Nevada desert where they could be vulnerable to Russians’ long-range missile attack!
“Who is Who” on
www.VP.org
The field of vulnerable plaque is best owed to many known and unknown
scientists who have worked hard to shed light on our way to prevent and
eradicate heart attacks in the future. To see a more complete list please visit:
Natural History ofVulnerable Plaques
Illustrated:
~70%
Percent of stenosis
Frequency of plaques
“Risk” per each plaque
Culprit Risk per each type of Vulnerable Plaque
(Log)
Culprit lesions found in autopsy series of acute MI
Different Types of Plaque Vulnerable to Thrombosis
All
Male
Female
~10% <5% ~20%
50%
Angiography
~80% <5% ~20%
~55% ~20%
<5%
<5% ~20%
Rupture Prone Eroded Calcified NoduleHemorrhage
Positive Remodeling
Fissured /Healed
Natural History of Vulnerable Atherosclerotic Plaques
Ruptured Plaques (~70%)1. Stenotic (~20%)2. Non-stenotic (~50%)
Non-ruptured Plaques (~ 30%)1.Erosion (~20%)2.Calcified Nodule (~5%)3.Others / Unknown (~5%)
Plaque Pathology Responsible for Coronary Thrombotic Death
In summary:
Culprit Plaque; a retrospective terminology
Vulnerable Plaque; a prospective terminology
Vulnerable Plaque = Future Culprit Plaque
Clarification of Terminologies
Rupture-Prone Plaque
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Macrophage
Necrotic lipid core
Thin fibrous cap
Eroded Plaque
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Endothelial denudation
Proteoglycans
Fissured / Healed Plaque
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Mural thrombi
Wounded plaque
Plaque with a Intimal Calcified Nodule
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Calcified nodule
Intra-Plaque Hemorrhage with Intact Cap
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Leaking angiogenesis or rupture of
vasa vaserum
Critically Stenotic but Asymptomatic Plaque
Naghavi et al, Cur Ath Rep 2001Vulnerable Plaque
>75% lumina
narrowing
Different Types of Vulnerable Plaques Major Underlying Cause of
Acute Coronary Events
NormalRupture-prone
Fissured ErodedCritical Stenosis Hemorrhage
Naghavi et al, Cur Ath Rep 2001
Emerging Techniques for Detection of
Vulnerable Plaque
Emerging Diagnostic Techniques A. Invasive Techniques
AngioscopyIntravascular Ultrasound (IVUS)Intravascular Thermography
Intravascular Optical Coherence Tomography (OCT)Intravascular Elastography
Intravascular and Transesophageal MRIIntravascular Nuclear Imaging
Intravascular Electrical Impedance ImagingIntravascular Tissue DopplerIntravascular Shear Stress ImagingIntravascular (Photonic) Spectroscopy
- Raman Spectroscopy
- Near-Infrared Diffuse Reflectance Spectroscopy
-Fibrousis and lipid measurement
-pH and lactate measurement
- Fluorescence Emission Spectroscopy
- Spectroscopy with contrast media
… Invasive Techniques
Intravascular (Photonic) Spectroscopy
Intra-coronary assessment of endothelial function
Intra-coronary measurement of MMPs and cytokines
Emerging Diagnostic TechniquesB. Non-Invasive Techniques:A. MRI
1- MRI without contrast media
2- MRI with contrast media: Gadolinium-DPTA
2- MR Imaging of Inflammation: Super Paramagnetic Iron Oxide (SPIO and USPIO)
3- MR Imaging of Thrombosis using monoclonal Ab
B. Electron Beam Tomography (EBT)
C. Multi-Slice Fast Spiral / Helical Computed Tomography
D. Nuclear Imaging (18-FDG, MCP-1, Annexin V, CD40)
Emerging Diagnostic TechniquesC. Blood Tests / Serum Markers
- CRP
- ICAM-1, VCAM, p-Selectin, sCD40-L
- Proinflamatory cytokines
- Lp-PLA2
- Ox-LDL Ab
- PAPP-A
D. Endothelial Function Test-Intra coronary acethylcholine test-Noninvasive flow mediated dilatation of
brachial artery- Anti-body against endothelial cells
Angioscopy
Advantages:Intuitive (anatomic) Simple (easy to understand)
Disadvantages:Visualizes only the surface of the plaqueRequires a proximal occluding balloonThe spatial resolution is limited
Glistening yellow plaque
Uchida et al, Japan
Intravascular Ultrasound (IVUS):
Advantage:Reveals the morphology of the plaqueDiffers between soft (hypo-echoic) and Hard (hyper-echoic) plaques
Disadvantages:Doesn’t give information about plaque inflammationLow spatial resolution (~ 200 m)
Nissen, Yock, and Fitzgerald
Optical Coherence Tomography (OCT) Advantage:
Very high-resolution
Disadvantages:Needs continuous saline wash / proximal occlusion Limited penetration Does not give information about plaque inflammation
Light Lab Inc.Mark Brezinski, James Fujimoto, Eric Swanson
Intravascular Thermography
Advantages:Simplicity in theory; hot plaque Gives information about plaque inflammation
Disadvantages:Plaque temperature is affected by blood flow
Volcano Therapeutics Inc.
Casscells W, et al.Thermal detection of cellular infiltrates in living atherosclerotic plaques: possible implications for plaque rupture and thrombosis.Lancet. 1996 May 25;347(9013):1447-51.
Vulnerable plaques are hot and acidic!
Ward Casscells and James Willerson showed ex-vivo that human carotid atherosclerotic plaques have temperature heterogeneity and plaques with thinner cap and higher macrophage infiltration give off more heat. Two years later Morteza Naghavi invented Thermosensor Basket catheter and showed invivo temperature heterogeneity in Hypercholestrolemic Dogs and Watanabe Rabbits. Coincidentally Stefanadis et al in 1999 confirmed significant temperature heterogeneity invivo in patients with unstable angina and acute MI.
Stefanadis C, et al.Thermal heterogeneity within human atherosclerotic coronary arteries detected in vivo: A new method of detection by application of a special thermography catheter.Circulation. 1999 Apr 20;99(15):1965-71.
Photonic Spectroscopy
Advantage: Chemical compounds
Disadvantage:Based on statistical analysis and calibration is always an issueS/N is a serious problem Still not proven to be able to distinguish vulnerable plaques from stable ones
Near Infrared Reflectance Spectroscopy
InfraReDx Inc.
NIR Spectroscopy
Robert Lodder, James Muller, and Pedro Moreno
Intravascular Elastography
Advantages:Provides novel information, showing stiffness Small added cost to IVUS
Disadvantage:Does not give any chemical – compositional data, nor shows inflammation
de Korte et al. Thorax Center, Erasmus University Rotterdam
Intravascular Nuclear Imaging Immuno-scintigraphy
Advantage:One may use radio-labeled antibodies to detect specific antigens in plaque like MCP-1
Disadvantages:Radiation and safety problems Poor resolution and flow artifacts Lack of specificity
ImetrX Inc.William Strauss and Vartan Ghazarossian
Magnetic Resonance ImagingPlaque Characterization and Angiography
Advantages:Lack of ionizing radiation Non-invasive Provides enormous information about flow as well as plaqueEnhancement by contrast agents and NMR spectroscopy
Disadvantages:Ineligibility of patients with metal prosthesesHigh costLonger time for adoption by cardiologists
Human Carotid Plaque
CCA
Carotid bifurcation
ICA stenosis & plaque
Courtesy of
Dr. Chun Yuan University of Washington Seattle
Human Carotid Plaque
Courtesy of
Dr. Chun Yuan
University of Washington
Fuster and Fayad and colleagues reinforced earlier MRI investigation of plaque for invivo non-invasive detection of vulnerable plaque with large lipid pool and thin fibrous caps.
Noninvasive Coronary Vessel Wall and Plaque Imaging With Magnetic Resonance Imaging
René M. Botnar; Matthias Stuber; Kraig V. Kissinger; Won Y. Kim; Elmar Spuentrup; Warren J. Manning.
Circulation. 2000;102:2582
Intravascular MRI
Advantages:Lack of ionizing radiation High resolution Potential for NMR spectroscopy
Disadvantages:Invasive and slower than fluoroscopyNeeds open/short bore high field magnetLonger time for adoption by cardiologists
Surgi-Vision Inc.Ergin Atalar
IVUS
Coronary Calcium ImagingEBT and MSCT
Advantages:Quick and easy Provide information about total burden of atherosclerosis
Disadvantages:Cannot distinguish vulnerable from stable plaque
(poor plaque characterization)Inadequate specificity, may not accurately predict near future eventMay not be suitable for monitoring treatment
Calcium Score
Imatron Inc.Rumberger, Aard, Raggi, and others
Race for Non-Invasive Coronary Angiography
• Multi-Slice Fast Computed Tomography (MSCT)
• Magnetic Resonance Angiography (MRA)
• Electron Beam Tomography (EBT)
Plaque Morphology vs.
Plaque Activity
Why do we need both?
Morphology vs. Activity Imaging
Inactive and non-inflamed plaque
Active and inflamed
plaque Appear Similar in
IVUS OCT MRI w/o CM
Morphology
Show Different
Activity
Thermography, Spectroscopy, immunoscientigraphy, MRI with
targeted contrast media…
High Level of Sensitivity and Specificity Needed
• Knowing the extensive prevalence of atherosclerosis, in order to accurately detect vulnerable plaques and vulnerable patients, it is imperative to obtain information about both structure and activity of plaque assuring a minimum of false positive and false negative results.
NO MORE TREADMILL TEST!
Potential Intravascular Combinations:• IVUS + Thermography• OCT + Thermography• OCT + NIR Spectroscopy• IVUS + Raman Spectroscopy• …
Potential Non-Invasive Combinations:• CRP + Calcium Score • CRP + Calcium Score + Framingham Risk Factors• Pro-inflammatory cytokines + Calcium Score• …
… the question is not only vulnerable plaque
The Question seems to be MORE THAN ONE:
2.Who has vulnerable blood?
3. Who has a vulnerable heart?
4. Who is a vulnerable patient?
1.Who has vulnerable plaque?√
Who Has Vulnerable Blood?
• Patients whose blood tends to create an occlusive thrombus on a vulnerable plaque, thereby resulting in an acute clinical syndrome.
• In other words:
Who has hyper-coagulable or “vulnerable blood”?
Who Has A Vulnerable Heart?
• Those patients whose heart is more sensitive to an acute ischemic episode due thereby resulting in a fatal arrhythmia and sudden out-of-hospital cardiac arrest?
• In other words:
Who has arhytmogenic or “vulnerable heart”?
Who Is A Vulnerable Patient?
A patient with a high likelihood of plaque, blood, and heart vulnerability
What is patient’s total Vulnerability Score (VP Score)
An index of having coronary event in the next 12 months (1 year)
Prevention of unheralded acute coronary events by early detection and treatment
of vulnerable plaques/patients.
The Grand Goal:
2001 2050
Genomic
Proteomic
2010 2020 2030 2040
Cellomic?!
VP Treatment
Home-based VP Screening Test
Heart Attack
Eradicated
Annual Death of MI
<10,000
Cloning Heart
VP Rx as OTC or Vaccine?
Eradication of Heart Attack
VP Detection
Mission:
Association for Eradication of Heart Attack
www.VP.org
WithSPECIAL THANKS TO:
Ward Casscells, MD
Mohammad Madjid, MD
Reza Mohammadi, MD
Mohammed Reza Khan, MD
Chief Editor, VP.org
Eric Jarvis, Executive Director, VP.org
Parsa Mirhaji MD, Chief IT Division, VP.org
Alireza Zarrabi MD, Chief VP Watch, VP.org
Shayda Katouzian, IT Specialist, VP.org
Cornelius Nwora MD, VP Patent Watch, VP.org
Silvio Litovsky MD, VP Watch Consultant, VP.org
Maziar Azadpour MD, VP Watch Consultant, VP.org
Paul Cherukuri, Medical Student, VP.org
Marilyn Sander, Executive Assistant, VP.org
Laura Liles, Science Writer, VP.org
Dot Jarvis, Graphic Designer & Artist, VP.org
November 7, 2001Houston, Texas
USA3D Animation:Mark Johnson
Narration:Jessica Townsend
We are pleased to have Mark and Jessica with VP.org
Business @ the Speed of Thought
William H. GatesChairman and Chief Software
ArchitectMicrosoft Corporation
Research @ the Speed of Internet!
Mort Gates!!!
Morteza Naghavi MD Founder of VP.org
“We will do with heart attack what our ancestor scientists did with smallpox”