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Postintervention Continuum of Care Update: Ultrasound Assessment of Plaque Dynamics

• Lipids and plaque on ultrasound: New views and new dimensions

This slide lecture material is an update to the core curriculum entitled Postintervention Continuum of Care: Focus on Lipids

This new set of slides on groundbreaking intravascular ultrasound studies provides us with important insights into atherosclerotic disease. These slides were developed following an ICSG faculty update conference in February 2000.

Overall, these slides and their accompanying content points address the vascular remodeling that renders most atheromas invisible to angiography; the evidence that stenotic lesions represent only a small proportion of the total disease burden; and strategies for risk management in the days and months following successful intervention.

Introduction

The angiogram is considered by most physicians to be the gold standard for defining coronary anatomy. However, angiography is a 2-dimensional representation of a complex 3- dimensional structure. In contrast, intravascular ultrasound (IVUS) provides real-time, full-motion, cross-sectional images of the vessel wall. IVUS studies have provided us with important insights into atherosclerotic disease.

In particular, we now know that vascular remodeling preserves lumen size until relatively late in the disease process and that angiography consistently underestimates the extent of disease. Coronary artery disease (CAD) is not a disease of the lumen; it is a disease of the vessel wall. The natural history of CAD is determined for the most part by the behavior of plaque in the vessel wall. Percutaneous coronary intervention (PCI) can relieve angina caused by a stenotic lesion. However, data suggest that the angiographically normal segment used as a reference during PCI may be 40% occupied by plaque; and it is rupture of this plaque within the wall that causes an infarction. Consequently, aggressive lipid lowering (with statins in the majority of patients) is required following PCI if long-term morbidity and mortality are to be favorably affected.

The attached slide materials are designed to provide an update on these advances. They are based on a presentation by Steven E. Nissen, MD, at an Interventions in Cardiology Study Group (ICSG) faculty update conference. The IVUS images were made at the Cleveland Clinic Intravascular Ultrasound Research Laboratory.



Published by Medical Education Consultants, Inc. (MEDCON), on behalf of the University of Florida College of Medicine. Supported by an unrestricted educational grant from Pfizer and Parke-Davis.

Copyright © 2000.

The editorial content of this program expresses the views of the individual contributors and does not necessarily reflect the views or recommendations of the University of Florida College of Medicine, Pfizer, Parke-Davis, or the publisher. The indications and dosages of drugs discussed in this program may vary from those approved by the Food and Drug Administration (FDA). The reader is advised to consult the full prescribing information for each medication prior to use.


Coronary disease in the United States

Download NISSEN%20ICSG.ppt (34 slides - 9.6MB)

Coronary disease in the United States Cardiovascular disease: Leading cause of death in US women Normal trilaminar coronary morphology Atherosclerosis: Traditional vs contemporary model Glagov’s coronary remodeling hypothesis Remodeling in an angiographically “normal” artery Remodeling preserves lumen size Mechanisms of false-negative angiography Angiographically inapparent coronary atherosclerosis: Disease burden in angiographically “normal” arteries Prevalence of atherosclerosis by donor age Coronary stenosis severity prior to MI Plaque rupture proximal to a severely stenotic lesion Atheroma rupture: Ultrasound features AVERT: Ischemic events at 18 months Anatomy of atherosclerotic plaque Plaque morphology: Vulnerable vs stable Remodeling: Stable and unstable lesions Rupture in bulky, remodeled atheroma: Angiographic findings Rupture in bulky, remodeled atheroma: IVUS findings Rupture in bulky, remodeled atheroma Stable angina with negative remodeling Potential role of MMP 3 in positive remodeling Clinical vs angiographic improvement Regression of donor CAD Glagov’s coronary remodeling hypothesis: Y2K Relationship between CHD events and LDL-C Comparison of LDL-C lowering by statins REVERSAL: Study design REVERSAL: Atheroma measurements REVERSAL: Number of sites evaluated ‘Minor’ luminal irregularity ‘Minor’ luminal irregularity: IVUS findings Clinical challenge

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