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  • Review Article
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Clinical classification of plaque morphology in coronary disease

Nature Reviews Cardiology volume 11, pages 379–389 (2014)Cite this article

Subjects

Key Points

  • Ex vivo studies of the coronary arteries have demonstrated the accuracy of optical coherence tomography imaging for definition of plaque characteristics

  • Whereas thin fibrous caps and necrotic cores indicate that plaques are susceptible to rupture, no characteristic features are known to identify plaques amenable to erosion

  • Clinical identification of plaques that cause acute coronary events is now feasible; such events might be characterized as being associated with ruptured or intact fibrous caps

  • Randomized studies might enable us to establish the safety of avoiding stent implantation in acute coronary events associated with intact fibrous caps

  • Randomized studies might also establish whether pre-emptive treatment of plaques vulnerable to rupture would prevent acute events

Abstract

In published post-mortem pathological studies, more than two-thirds of acute coronary events are associated with the rupture of lipid-rich, voluminous, and outwardly remodelled plaques covered by attenuated and inflamed fibrous caps in the proximal part of coronary arteries. Superficial erosion of the plaques is responsible for most of the remaining events; the eroded plaques usually do not demonstrate much lipid burden, do not have thin fibrous caps, are not positively remodelled, and are not critically occlusive. Both noninvasive and invasive imaging studies have been performed to clinically define the plaque characteristics in acute coronary syndromes in an attempt to identify the high-risk plaque substrate susceptible to development of an acute coronary event. Optical coherence tomography (OCT)—an intravascular imaging modality with high resolution—can be used to define various stages of plaque morphology, which might allow its use for the identification of high-risk plaques vulnerable to rupture, and their amenability to pre-emptive interventional treatment. OCT might also be employed to characterize plaque pathology at the time of intervention, to provide a priori knowledge of the mechanism of the acute coronary syndrome and, therefore, to enable improved management of the condition.

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Figure 1: Intimal thickening and intimal xanthoma.
Figure 2: Pathological intimal thickening.
Figure 3: Fibroatheroma.
Figure 4: Thin-cap fibroatheroma with extensive haemorrhage.
Figure 5: Ruptured plaque associated with nonocclusive luminal thrombus.
Figure 6: Plaque erosion.
Figure 7: Calcified nodule.
Figure 8: Healed plaque rupture.
Figure 9: Two pathologically distinct types of acute coronary event.

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Acknowledgements

St. Jude Medical (USA) and Terumo Corporation (Japan) provided the major source of research funds for the ex vivo optical coherence tomography/optical frequency domain imaging study, with other support from CVPath Institute, Inc., USA. F.O. is supported by a research fellowship from the Uehara Memorial Foundation (Japan).

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Authors and Affiliations

  1. Cardiovascular Pathology Inc., 19 Firstfield Road, Gaithersburg, 20878, MD, USA

    Fumiyuki Otsuka, Michael Joner & Renu Virmani

  2. San Giovanni Addolorata Hospital and CLI Foundation, Via Amba Aradam, 8, Rome, 00184, Italy

    Francesco Prati

  3. Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, 10029, NY, USA

    Jagat Narula

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Contributions

F.O., F.P., and J.N. researched data for the article. M.J., R.V., and J.N. substantially contributed to discussion of content. F.O., M.J., R.V., and J.N. wrote the manuscript. M.J., F.P., R.V., and J.N. reviewed and edited the manuscript before submission.

Corresponding author

Correspondence to Jagat Narula.

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Competing interests

M.J. receives honoraria from Abbott Vascular, Biotronik, Medtronic, and St. Jude Medical, and is a consultant for Biotronik and Cardionovum. R.V. receives research support from Abbott Vascular, BioSensors International, Biotronik, Boston Scientific, Medtronic, MicroPort Medical, OrbusNeich Medical, SINO Medical Technology, and Terumo Corporation. She also has speaking engagements with Merck, receives honoraria from Abbott Vascular, Boston Scientific, Lutonix, Medtronic, and Terumo Corporation, and is a consultant for 480 Biomedical, Abbott Vascular, Medtronic, and W.L. Gore. J.N. has received research grants (to his institution in the form of imaging equipment) from GE Healthcare and Philips Healthcare, and has received honoraria from GE Healthcare and Philips Healthcare as a member of their advisory boards. F.O. and F.P. declare no competing interests.

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Otsuka, F., Joner, M., Prati, F. et al. Clinical classification of plaque morphology in coronary disease. Nat Rev Cardiol 11, 379–389 (2014). https://doi.org/10.1038/nrcardio.2014.62

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