Role of Lipid-Lowering and Anti-Inflammatory Therapies on Plaque Stabilization.

Atherosclerosis is the predominant underlying etiopathology of coronary artery disease. Changes in plaque phenotype from stable to high risk may spur future major adverse cardiac events (MACE). Different pharmacological therapies have been implemented to mitigate this risk. Over the last two decades, intravascular imaging modalities have emerged in clinical studies to clarify how these therapies may affect the composition and burden of coronary plaques. Lipid-lowering agents, such as statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 inhibitors, were shown not only to reduce low-density lipoprotein levels and MACE but also to directly affect features of coronary plaque vulnerability. Studies have demonstrated that lipid-lowering therapy reduces the percentage of atheroma volume and number of macrophages and increases fibrous cap thickness. Future studies should answer the question of whether pharmacological plaque stabilization may be sufficient to mitigate the risk of MACE for selected groups of patients with atherosclerotic coronary disease.

Sex-specific associations between the environmental exposures and low-grade inflammation and increased blood pressure in young, healthy subjects.

Long-term exposures to environmental factors including airborne as well as noise pollutants, are associated with cardiovascular risk. However, the influence of environmental pollution on the young population is controversial. Accordingly, we aimed to investigate the relationships between long-term exposures to different environmental factors and major cardiovascular and inflammatory parameters and biomarkers in young, healthy subjects. Representative sample of permanent residents of two cities differing in air and noise pollution levels, aged 15-21 years, were recruited. Krakow and Lublin, both located in southern Poland, were chosen in relation to their similarities in demographic and geopolitical characteristics, but differences in air pollution (higher in Krakow) and noise parameters (higher in Lublin). A total of 576 subjects were studied: 292 in Krakow and 284 in Lublin. All subjects underwent health questionnaire, blood pressure measurements and biomarker determinations. Inflammatory biomarkers, such as CRP, hs-CRP, fibrinogen as well as homocysteine were all significantly higher in subjects living in Krakow as opposed to subjects living in Lublin (for hsCRP: 0.52 (0.32-0.98) mg/l vs. 0.35 (0.22-0.67) mg/l; p < 0.001). Increased inflammatory biomarker levels were observed in Krakow in both male and female young adults. Interestingly, significant differences were observed in blood pressure between male and female subjects. Males from Krakow had significantly higher mean systolic blood pressure (127.7 ± 10.4 mm/Hg vs. 122.4 ± 13.0 mm/Hg; p = 0.001), pulse pressure (58.7 ± 8.9 mm/Hg vs. 51.4 ± 12.3 mm/Hg; p < 0.001) and lower heart rate (p < 0.001) as compared to males living in Lublin. This was not observed in young adult females. Long-term exposure to environmental factors related to the place of residence can significantly influence inflammatory and cardiovascular parameters, even in young individuals. Interestingly, among otherwise healthy young adults, blood pressure differences exhibited significant variations based on biological sex.

Intracoronary Imaging of Vulnerable Plaque-From Clinical Research to Everyday Practice.

The introduction into clinical practice of intravascular imaging, including intravascular ultrasound (IVUS), optical coherence tomography (OCT) and their derivatives, allowed for the in vivo assessment of coronary atherosclerosis in humans, including insights into plaque evolution and progression process. Intravascular ultrasound, the most commonly used intravascular modality in many countries, due to its low resolution cannot assess many features of vulnerable plaque such as lipid plaque or thin-cap fibroatheroma. Thus, novel methods were introduced to facilitate this problem including virtual histology intravascular ultrasound and later on near-infrared spectroscopy and OCT. Howbeit, none of the currently used modalities can assess all known characteristics of plaque vulnerability; hence, the idea of combining different intravascular imaging methods has emerged including NIRS-IVUS or OCT-IVUS imaging. All of those described methods may allow us to identify the most vulnerable plaques, which are prone to cause acute coronary syndrome, and thus they may allow us to introduce proper treatment before plaque destabilization.

Coronary plaque and clinical characteristics of South Asian (Indian) patients with acute coronary syndromes: An optical coherence tomography study.

BACKGROUND: South Asians, and Indians in particular, are known to have a higher incidence of premature atherosclerosis and acute coronary syndromes (ACS) with worse clinical outcomes, compared to populations with different ethnic backgrounds. However, the underlying pathobiology accounting for these differences has not been fully elucidated. METHODS: ACS patients who had culprit lesion optical coherence tomography (OCT) imaging were enrolled. Culprit plaque characteristics were evaluated using OCT. RESULTS: Among 1315 patients, 100 were South Asian, 1009 were East Asian, and 206 were White. South Asian patients were younger (South Asians vs. East Asians vs. Whites: 51.6 ± 13.4 vs. 65.4 ± 11.9 vs. 62.7 ± 11.7; p < 0.001) and more frequently presented with ST-segment elevation myocardial infarction (STEMI) (77.0% vs. 56.4% vs. 35.4%; p < 0.001). On OCT analysis after propensity group matching, plaque erosion was more frequent (57.0% vs. 38.0% vs. 50.0%; p = 0.003), the lipid index was significantly greater (2281.6 [1570.8-3160.6] vs. 1624.3 [940.9-2352.4] vs. 1303.8 [1090.0-1757.7]; p < 0.001), and the prevalence of layered plaque was significantly higher in the South Asian group than in the other two groups (52.0% vs. 30.0% vs. 34.0%; p = 0.003). CONCLUSIONS: Compared to East Asians and Whites, South Asians with ACS were younger and more frequently presented with STEMI. Plaque erosion was the predominant pathology for ACS in South Asians and their culprit lesions had more features of plaque vulnerability. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov, NCT03479723.

Five-year report from the Polish national registry on percutaneous coronary interventions with a focus on coronary artery perforations within chronic total occlusions.

INTRODUCTION: Patients treated within chronic total occlusions (CTO) using percutaneous coronary intervention (PCI) are at increased risk of periprocedural complications. AIM: To assess the frequency of periprocedural complications with particular emphasis on coronary artery perforations (CAPs) among patients treated with PCIs stratified according to CTOs and their predictors. MATERIAL AND METHODS: Based on a nationwide registry (ORPKI), we analysed 535,853 patients treated with PCI between 2014 and 2018. The study included 12,572 (2.34%) patients treated with CTO PCI. We compared CTO PCI to a non-CTO PCI group before and after propensity score matching (PSM). Multifactorial mixed regression models were used to assess predictors of periprocedural complications and CAPs which occurred within the catheterization laboratory. RESULTS: Frequencies of all periprocedural complications (2.75% vs. 1.93%, p < 0.001) and CAP (0.72% vs. 0.16%, p < 0.001) were significantly higher in the CTO PCI group. Multifactorial regression analysis performed in the all-comers group of patients treated with PCI showed that PCI within CTO was related to a higher CAP rate (odds ratio (OR) = 2.18; 95% confidence interval (CI): 1.68-2.82, p < 0.001). After PSM, we extracted 5,652 patients treated within CTO and 5,652 patients with non-CTO PCI. CTO PCI was also related to a higher frequency of CAPs (OR = 1.89; 95% CI: 1.11-3.31, p = 0.01). CONCLUSIONS: The frequency of periprocedural complications and CAPs remained stable during the assessed period of time. CTO PCI was confirmed to be among the predictors of increased CAP rate in the overall group of patients treated within CTO.

Differences in patients and lesion and procedure characteristics depending on the age of the coronary chronic total occlusion.

INTRODUCTION: Whether duration of chronic total occlusion (CTO) affects lesion and procedural characteristics remains largely unknown. AIM: To investigate whether CTO duration influences lesion characteristics and revascularization success. MATERIAL AND METHODS: EuroCTO Registry data on patients who had CTO percutaneous coronary intervention between January 2015 and April 2017 were analyzed. Three groups were created based on occlusion age: 3 to 6 months (n = 1415), 7 to 12 months (n = 973), > 12 months (n = 1656). RESULTS: Patients with greater CTO duration were older (63.0 (56.0-70.0); 63.0 (56.0-71.0); 66.0 (59.0-73.0) years respectively; p < 0.001), had more 3-vessel disease (32.2%; 30.9%; 46.1% respectively; p < 0.001) and more frequent prior coronary artery bypass grafting (8.2%; 9.9%; 29.4% respectively; p < 0.001). In multivariate analysis, occlusion duration was associated with moderate/severe calcification (OR = 1.52; 95% CI: 1.28-1.80; p < 0.001), lesion length > 20 mm (OR 1.77; 95% CI 1.49-2.10; p < 0.001), and collateral circulation Werner type 2 (OR = 1.20; 95% CI: 1.01-1.43; p = 0.041). The CTO duration was associated with lower procedural success (OR for success 0.60; 95% CI: 0.46-0.79; p < 0.001). In multivariate analysis in-hospital adverse events did not differ according to duration of CTO. CONCLUSIONS: Coronary artery CTO duration is associated with greater extent of calcification, lesion length, development of collateral circulation and, most importantly, with lower procedural success.

Three-Dimensional Fibrous Cap Structure of Coronary Lipid Plaque　- ST-Elevation Myocardial Infarction vs. Stable Angina.

BACKGROUND: Fibrous cap thickness (FCT) is one of the key features of coronary vulnerable plaque. FCT is measured at an arbitrary point, determined on visual assessment of 2-D cross-sectional imaging. This method has poor reproducibility. The aim of this study was to compare the 3-D structure of FC in non-culprit lipid plaques between patients with ST-elevation myocardial infarction (STEMI) and with stable angina (SA) on optical coherence tomography. Methods and Results: A total of 54 non-culprit plaques from 23 STEMI and 23 SA patients were evaluated. Thin cap fibroatheroma (TCFA), defined as lipid plaque with FCT <80 µm, was identified using a novel algorithm. The number of TCFA, surface area of each TCFA, and the sum total area of TCFA in the target vessel were measured. Patients with STEMI had a greater median number of TCFA (9, IQR 1-17 vs. 2, IQR 0-5; P=0.002), the largest median single TCFA area (0.40, IQR 0.14-0.69 vs. 0.08, IQR 0.04-0.16 mm2; P<0.001) and median sum total area of TCFA (1.04, IQR 0.41-1.95 vs. 0.24, IQR 0.08-0.48 mm2, P<0.004). CONCLUSIONS: Patients with STEMI, as compared with those with SA, have greater vulnerability to non-culprit plaque.

Does the effectiveness of recanalization of chronic occlusion depend on the location of the obstruction?

INTRODUCTION: In past studies, it has been questioned whether success of recanalization of chronic total occlusion (CTO) depends on the location of the occlusion - the circumflex artery (Cx) was considered as the most difficult to open. AIM: To determine whether the effectiveness of recanalization of CTO depends on the location of the obstruction. MATERIAL AND METHODS: From January 2011 to January 2016, a single operator dedicated to chronic total occlusions performed in our center 357 procedures on 337 patients. RESULTS: Among 337 patients included in the study, 83.4% were male. Mean age was 62.8 ±9.3 years. Most of the patients had hypertension (86.4%) and hyperlipidemia (99.4%), and 28.8% of them had diabetes. The most frequently opened artery was the right coronary artery (RCA; 52.4%), followed by the left anterior descending artery (LAD; 29.4%), and last the Cx (18.2%). The mean J-CTO score was comparable between the three groups. The success rate of recanalization of CTO was similar for all arteries: 84.5% in the RCA, 81.9% in the LAD and 89.2% in the Cx (overall p = 0.437). Neither procedural complications nor adverse events depended on the location of the CTO. CONCLUSIONS: Our study shows the same efficacy of CTO procedures of all epicardial arteries. We did not observe that effectiveness of recanalization of CTO depends on the location of the obstruction.

Differences in coronary plaque morphology between East Asian and Western White patients: an optical coherence tomography study.

AIMS: Prevalence of coronary artery disease as well as cardiac mortality varies between Asian and White patients. However, the link between race and plaque characteristics in patients with coronary artery disease remains largely unexplored. Thus, we aimed to investigate the detailed culprit plaque characteristics between East Asian and White patients using optical coherence tomography. PATIENTS AND METHODS: A total of 101 East Asians were matched to 101 White patients. Matching parameters included age, sex, clinical presentation, hyperlipidemia, diabetes mellitus, and lesion location. RESULTS: There were no differences in underlying pathology (rupture vs. erosion) of acute coronary syndrome (P=0.935). Lesion length was longer (18.0±6.0 vs. 14.6±5.4 mm; P<0.002), lipid length was greater (9.4±4.6 vs. 7.2±3.8 mm; P<0.023), lipid index was higher (1635±987 vs. 1104±730; P=0.002), and mean reference area was larger (8.1±3.0 vs. 6.5±2.4 mm; P<0.021) in White patients compared with East Asian patients. CONCLUSION: There are significant differences in plaque morphology between East Asian and White patients even after controlling for confounders. Our findings underscore key differences in atherosclerosis between East Asian and White populations, and may have to be taken into consideration when interpreting the results of future research.