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Attenuated Plaque Detected by Intravascular Ultrasound

Clinical, Angiographic, and Morphologic Features and Post-Percutaneous Coronary Intervention Complications in Patients With Acute Coronary Syndromes

Sung Yun Lee, MD^_*, Gary S. Mintz, MD, Seok-Yeon Kim, MD^_*, Young Joon Hong, MD^_*, Sang Wook Kim, MD^_*, Teruo Okabe, MD^_*, Augusto D. Pichard, MD^_*, Lowell F. Satler, MD^_*, Kenneth M. Kent, MD, PhD^_*, William O. Suddath, MD^_*, Ron Waksman, MD^_*, Neil J. Weissman, MD^_*,_*

^_* Cardiovascular Research Institute/MedStar Research Institute, Washington Hospital Center, Washington, DC
Cardiovascular Research Foundation, New York, New York

^_* Reprint requests and correspondence: Dr. Neil J. Weissman, 100 Irving Street, NW, EB # 5123, Washington, DC 20010 (Email: neil.j.weissman{at}medstar.net).

Objectives: We evaluated the clinical significance of attenuated plaque (hypoechoic plaque with deep ultrasound attenuation).

Background: Attenuated plaques are unusual intravascular ultrasound (IVUS) findings in patients with acute coronary syndrome (ACS).

Methods: We reviewed clinical presentations and angiographic and pre-intervention IVUS findings in 293 ACS patients undergoing percutaneous coronary intervention (PCI) without a distal protection device: 187 with non–ST-segment elevation myocardial infarction (NSTEMI) and 106 with ST-segment elevation myocardial infarction (STEMI).

Results: Attenuated plaque was observed in 75 patients (25.6%): 39.6% of STEMI versus 17.6% of NSTEMI (p < 0.001). (We also reviewed 100 randomly selected patients with stable angina and pre-intervention IVUS; none had attenuated plaque.) Overall, in ACS patients with attenuated plaques: 1) the level of C-reactive protein was higher; 2) angiographic thrombus and initial coronary flow Thrombolysis In Myocardial Infarction flow grade <2 were more common; and 3) IVUS lesion site plaque burden and remodeling index were significantly greater, lesion site luminal dimensions significantly smaller, and thrombus, positive remodeling, and plaque rupture were more common. No-reflow (26.7% vs. 4.6%, p < 0.001) and deteriorated post-PCI coronary blood flow (8.0% vs. 2.8%, p = 0.001) were higher. In ACS patients with normal coronary blood flow at baseline, deterioration in the coronary blood flow post-PCI was more common in lesions with attenuated plaque.

Conclusions: Attenuated plaque was more common in ACS patients with STEMI than NSTEMI. Attenuated plaque in ACS patients was associated with a higher C-reactive protein level, more severe and complex lesion morphology, reduced coronary blood flow before PCI, and especially no-reflow after PCI.

Key Words: imaging • atherosclerosis • calcium

Abbreviations and Acronyms   ACS = acute coronary syndrome(s)   CSA = cross-sectional area   CTFC = corrected Thrombolysis In Myocardial Infarction frame count   EEM = external elastic membrane   IVUS = intravascular ultrasound   LAD = left anterior descending coronary artery   NSTEMI = non–ST-segment elevation myocardial infarction   PCI = percutaneous coronary intervention   P&M = plaque and media   RCA = right coronary artery   STEMI = ST-segment elevation myocardial infarction   TIMI = Thrombolysis In Myocardial Infarction

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