1. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Perspective:
Vulnerable Plaque
…or vessels, patients
or ??
Robert S. Schwartz, MD
Minneapolis Heart Institute
2. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
How to Cure Human Disease
1. Define the Disease
2.Associate it reliably
3.Find the Disease
4. Deliver the ‘Fix’
6. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
3 Autopsy Derived Groups
Acute MI
18 patients/337 segments
Stable Angina
5 Patients/76 segments
Controls (no CAD)
9 Patients/111 segments
Coronary
Inflammation
Is Diffuse
7. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Inflammatory Cell Count
Macrophages/Monocytes
CD-68 Positivity
T-Lymphocytes
CD-3 Positivity
Coronary
Inflammation
Is Diffuse
8. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
IRA
Segments
AMI
Non-IRA
segments
of AMI group
Controls
CD68 positive cells
monocytes/macrophag
es
38.0
+ 7.9%
35.3
+ 4.7%
1.0
+ 2.9%
CD3 positive cells
(T-lymphocytes)
17.7
+ 3.5%
20.9
+ 4.1%
7.6
+ 1.6%
Coronary Artery Inflammation Is Diffuse
JACC April 2005 Mauriello, Sangiorgi, Fratoni, Palmieri, Bonanno, Anemona Schwartz, Spagnoli
9. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Coronary Inflammation Is Diffuse
0
5
10
15
20
25
30
35
40
IRA Non-IRA Control
Macrophages Lymphocytes
JACC April 2005 Mauriello, Sangiorgi, Fratoni, Palmieri, Bonanno, Anemona Schwartz, Spagnoli
11. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Thermography
Will Thermography will
easily detect and localize
vulnerable plaque?
13. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Porcine Proximal LCX
10 days
Histopathology:
Chronic, superficial inflammation,
mainly mononuclear cells
¾ of the lumen circumflex
Temperature:
Circumferential and significantly increased
vessel wall temperature above 1.0°C
14. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Caveat:
Thermography and thermal
heterogeneity measures
appear highly flow
dependent. The methods
and devices can be
technically challenging.
Major differences exist
across published studies.
16. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Self-contained
portable MRI
catheter
Catheter Based MRI Imaging
17. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Ex-vivo MR imaging: human coronary arteries
Adaptive intimal
thickening
LAD atheroma
20. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Coronary Ruptured Plaque (CTA)
Aortic Penetrating Ulcer (MRA)
21. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Is Not ‘Soft Plaque”
MSCTA visualizes well
Questions:
Prevalence of isolated Uncalcified Plaque (no
associated calcified plaque)
Risk Factors associated
CTA and Uncalcified Plaque
22. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
506 unselected patients scanned for chest pain
16-Slice MSCTA
CTA and Uncalcified Plaque
23. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
30% (124/506 patients) had no calcification
CTA and Uncalcified Plaque
30%
70%
No Calcification
Calcification
24. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
44% (55/124 patients) had no plaque
CTA and Uncalcified Plaque
30%
70%
No Calcification
Calcification
25. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
51% (63/124patients) had uncalcified plaque
without severe stenosis
CTA and Uncalcified Plaque
51%
49%
No Stenosis
Stenosis
26. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
5% (6/124 patients) of Uncalcified Plaque had
significant stenosis
CTA and Uncalcified Plaque
5%
95%
Significant
Stenosis
No Signficiant
Stenosis
27. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Risk Factors and all uncalcified plaque
83% Smokers (former/current)
98% of patients with 0-3 Risk factors had no plaque or
<50% Stenosis
86% of patients with > 4 Risk factors had UCP and/or
significant stenosis
No patient with <2 Risk Factors had uncalcified
plaque
28. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Uncalcified plaque is prevalent in patients with chest
pain
Smoking may have significant impact on UCP
formation.
UCP prevalence is highly dependent on aggregate
coronary risk.
MSCTA appears useful for detecting both calcified
and noncalcified coronary plaque.
MSCTA and Uncalcified Plaque
29. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Observation:
Significant technical
developments are needed
for MRI. Problems of
Spatial and Temporal
Resolution, and Acquistion
remain a major
impediment to clinical
coronary imaging in living
patients.
31. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Culprit
Lesion
M-OA
M-LC
A-WJ
Unstable
E-KK M-UM
E-IM E-JS
A-MK
RECENT MI
UNSTABLE ANGINA
UNSTABLE ANGINA
Just proximal to
stented lesion
32. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Caveat
Intravascular Imaging
can localize thin-cap
fibroadenoma and lipid-
laden regions of
vulnerability.
But what does it mean?
33. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Raman Spectroscop
Scepanvic O, Galindo LH, Feld MS
34. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Now that we aren’t certain about diagnoses,
what about therapy?
Perspective: Imaging Vulnerable Plaque
35. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
%%
withwith
EvenEven
tt
00 33 1818 2121 2424 2727 303066 99 1212 1515
2020
1515
1010
55
00
Months of Follow-up
All-Cause Death, Non-Fatal MI, or
Urgent Revascularization
Pravastatin 40mgPravastatin 40mg
16.7%16.7%
Atorvastatin 80mgAtorvastatin 80mg
12.9%12.9%
25% RR25% RR
P = 0.0004P = 0.0004
36. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
16.7
20.5
33.3
16.7
6.4
3.9
1.3 1.3
0 0 0 0 0
0
5
10
15
20
25
30
35
Percent(%)
10
20
30
40
50
60
70
80
90
100
110
120
130
millimeters (mm)
Prox Mid Distal
p = 0.003
Distribution of Acute Coronary Occlusions
Left Anterior Descending Artery
(Normalized Segment Analysis)
37. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
0
10
20
30
40
50
60
70
80
90
100 0
10
20
30
40
50
60
70
80
90
100
110
120
130
millimeters (mm)
Percent(%)Acute Coronary Occlusions by Distance from
Left Anterior Descending Artery Ostium
38. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
How to Cure Human Disease
1. Define the Disease
Not Yet
2.Associate it reliably
Not Yet
3.Find the Disease
Not Yet
4. Deliver the ‘Fix’
Not Yet
39. The Minneapolis Heart
Institute Foundation
The Minneapolis
Heart Institute
Perspective:
Vulnerable Plaque
…or vessels, patients
or ??
Robert S. Schwartz, MD
Minneapolis Heart Institute
Notes de l'éditeur
&lt;number&gt;
So, given the impact that stents have on the vascular system, it is critical that the body’s response to this injury is in the form of controlled, healthy healing.
A few things to consider when evaluating DES are:
- The ability for certain compounds, such as paclitaxel, to selectively target smooth muscle cells at lower doses than endothelial cells, thereby allowing for endothelial cells to grow over the stent struts to create a slippery surface that is non-thrombogenic may be important.
- While controlling late loss is important, it may be equally important that there is a degree of consistency across trials and patient subsets. While achieving zero millimeters of late loss intuitively seems favorable, such a condition may not be conducive to healing.
- The presence of late incomplete apposition is of concern because blood may be able to flow behind the stent struts, which may lead to a complications.
- One of the important follow-up measurements in clinical trials is the progression of incomplete apposition. Gaps that form behind struts or increase in size can potentially cause blood to pool and clots to form (thrombus)
&lt;number&gt;
There are only a handful of radioisotopes with characteristics suitable for coronary Brachytherapy applications. Radioactive isotopes have a fixed half-life (the time it takes for the activity to drop by half). Their energies are also fixed.
These energies are dictated by the nuclear structure and cannot be altered. Therefore to reach a certain target with radioisotopes one must have the right energy. If the conditions between the isotope and the target are changed by the presence of foreign material with different properties than tissue the dose to the target may not be achieved.
As I mentioned earlier, beta sources have a limited depth of penetration which is adequate for a millimeter depth. On the other hand due to gamma&apos;s penetrating power it delivers a dose well beyond the treatment zone.
&lt;number&gt;
So, given the impact that stents have on the vascular system, it is critical that the body’s response to this injury is in the form of controlled, healthy healing.
A few things to consider when evaluating DES are:
- The ability for certain compounds, such as paclitaxel, to selectively target smooth muscle cells at lower doses than endothelial cells, thereby allowing for endothelial cells to grow over the stent struts to create a slippery surface that is non-thrombogenic may be important.
- While controlling late loss is important, it may be equally important that there is a degree of consistency across trials and patient subsets. While achieving zero millimeters of late loss intuitively seems favorable, such a condition may not be conducive to healing.
- The presence of late incomplete apposition is of concern because blood may be able to flow behind the stent struts, which may lead to a complications.
- One of the important follow-up measurements in clinical trials is the progression of incomplete apposition. Gaps that form behind struts or increase in size can potentially cause blood to pool and clots to form (thrombus)
&lt;number&gt;
There are only a handful of radioisotopes with characteristics suitable for coronary Brachytherapy applications. Radioactive isotopes have a fixed half-life (the time it takes for the activity to drop by half). Their energies are also fixed.
These energies are dictated by the nuclear structure and cannot be altered. Therefore to reach a certain target with radioisotopes one must have the right energy. If the conditions between the isotope and the target are changed by the presence of foreign material with different properties than tissue the dose to the target may not be achieved.
As I mentioned earlier, beta sources have a limited depth of penetration which is adequate for a millimeter depth. On the other hand due to gamma&apos;s penetrating power it delivers a dose well beyond the treatment zone.
&lt;number&gt;
There are only a handful of radioisotopes with characteristics suitable for coronary Brachytherapy applications. Radioactive isotopes have a fixed half-life (the time it takes for the activity to drop by half). Their energies are also fixed.
These energies are dictated by the nuclear structure and cannot be altered. Therefore to reach a certain target with radioisotopes one must have the right energy. If the conditions between the isotope and the target are changed by the presence of foreign material with different properties than tissue the dose to the target may not be achieved.
As I mentioned earlier, beta sources have a limited depth of penetration which is adequate for a millimeter depth. On the other hand due to gamma&apos;s penetrating power it delivers a dose well beyond the treatment zone.
&lt;number&gt;
There are only a handful of radioisotopes with characteristics suitable for coronary Brachytherapy applications. Radioactive isotopes have a fixed half-life (the time it takes for the activity to drop by half). Their energies are also fixed.
These energies are dictated by the nuclear structure and cannot be altered. Therefore to reach a certain target with radioisotopes one must have the right energy. If the conditions between the isotope and the target are changed by the presence of foreign material with different properties than tissue the dose to the target may not be achieved.
As I mentioned earlier, beta sources have a limited depth of penetration which is adequate for a millimeter depth. On the other hand due to gamma&apos;s penetrating power it delivers a dose well beyond the treatment zone.
&lt;number&gt;
There are only a handful of radioisotopes with characteristics suitable for coronary Brachytherapy applications. Radioactive isotopes have a fixed half-life (the time it takes for the activity to drop by half). Their energies are also fixed.
These energies are dictated by the nuclear structure and cannot be altered. Therefore to reach a certain target with radioisotopes one must have the right energy. If the conditions between the isotope and the target are changed by the presence of foreign material with different properties than tissue the dose to the target may not be achieved.
As I mentioned earlier, beta sources have a limited depth of penetration which is adequate for a millimeter depth. On the other hand due to gamma&apos;s penetrating power it delivers a dose well beyond the treatment zone.
&lt;number&gt;
There are only a handful of radioisotopes with characteristics suitable for coronary Brachytherapy applications. Radioactive isotopes have a fixed half-life (the time it takes for the activity to drop by half). Their energies are also fixed.
These energies are dictated by the nuclear structure and cannot be altered. Therefore to reach a certain target with radioisotopes one must have the right energy. If the conditions between the isotope and the target are changed by the presence of foreign material with different properties than tissue the dose to the target may not be achieved.
As I mentioned earlier, beta sources have a limited depth of penetration which is adequate for a millimeter depth. On the other hand due to gamma&apos;s penetrating power it delivers a dose well beyond the treatment zone.
&lt;number&gt;
There are only a handful of radioisotopes with characteristics suitable for coronary Brachytherapy applications. Radioactive isotopes have a fixed half-life (the time it takes for the activity to drop by half). Their energies are also fixed.
These energies are dictated by the nuclear structure and cannot be altered. Therefore to reach a certain target with radioisotopes one must have the right energy. If the conditions between the isotope and the target are changed by the presence of foreign material with different properties than tissue the dose to the target may not be achieved.
As I mentioned earlier, beta sources have a limited depth of penetration which is adequate for a millimeter depth. On the other hand due to gamma&apos;s penetrating power it delivers a dose well beyond the treatment zone.
&lt;number&gt;
So, given the impact that stents have on the vascular system, it is critical that the body’s response to this injury is in the form of controlled, healthy healing.
A few things to consider when evaluating DES are:
- The ability for certain compounds, such as paclitaxel, to selectively target smooth muscle cells at lower doses than endothelial cells, thereby allowing for endothelial cells to grow over the stent struts to create a slippery surface that is non-thrombogenic may be important.
- While controlling late loss is important, it may be equally important that there is a degree of consistency across trials and patient subsets. While achieving zero millimeters of late loss intuitively seems favorable, such a condition may not be conducive to healing.
- The presence of late incomplete apposition is of concern because blood may be able to flow behind the stent struts, which may lead to a complications.
- One of the important follow-up measurements in clinical trials is the progression of incomplete apposition. Gaps that form behind struts or increase in size can potentially cause blood to pool and clots to form (thrombus)