Identifying the Vulnerable Patient with Rupture-Prone Plaque

Leading causes of death for men and women in the United States. Atherosclerosis is the primary etiology of the first- (heart attack) and third- (stroke) leading causes of death, despite effective preventive treatments that are available.

Leading causes of death for women in the United States. A lesser known statistic in women with cardiovascular disease is that 1 in 3 will die of heart disease, making it the number 1 killer, far surpassing breast cancer, lung cancer, stroke, and other cancers. (Adapted from the National Heart, Lung and Blood Institute Web site.²)

Prevalence of conventional risk factors in patients with coronary artery disease (CAD). In this large pooled analysis of almost 88,000 patients with established CAD, 62.4% had only 0–1 of the 4 conventional CAD risk factors—hypertension, smoking, hypercholesterolemia, and diabetes mellitus.

Most acute myocardial infarctions (AMIs) present with <50% stenosis, and most sudden cardiac deaths are related to thin, fibrous cap and rupture-prone plaques. (A) Most (68%) AMIs occur at sites of <50% lumen stenosis, and the culprit lesion in AMI exhibits severe (>70%) stenosis in only 14% of cases. (B) A necropsy study found that in sudden cardiac death cases, 76% of culprit lesions involved rupture-prone plaque, and only 24% occurred at sites of severe luminal narrowing. (Adapted from Circulation.²⁵)

Rupture-prone and ruptured plaques at autopsy. As plaques mature, they develop thinner fibrous caps, and the lipid pool becomes a large necrotic core infiltrated with macrophages. When these lesions are stained for lipoprotein-associated phospholipase A₂, only the more advanced thin fibrous cap atheromas and ruptured plaques demonstrate intense staining (reddish-brown). (Illustration by Scott Barrows, Medical Illustrator, University of Illinois at Chicago.)