Author + information
- Received February 19, 2016
- Accepted April 16, 2016
- Published online June 5, 2017.
- Joo Myung Lee, MD, MPH, PhDa,
- Gilwoo Choi, PhDb,c,
- Doyeon Hwang, MDd,
- Jonghanne Park, MD, PhDd,
- Hyun Jin Kim, PhDb,
- Joon-Hyung Doh, MD, PhDe,
- Chang-Wook Nam, MD, PhDf,
- Sang-Hoon Na, MD, PhDg,h,
- Eun-Seok Shin, MD, PhDi,∗∗ ( )(, )
- Charles A. Taylor, PhDb,j and
- Bon-Kwon Koo, MD, PhDd,h,∗ ()
- aDivision of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- bHeartFlow, Inc., Redwood City, California
- cDepartment of Surgery, Stanford University Medical Center, Stanford, California
- dDepartment of Medicine, Seoul National University Hospital, Seoul, South Korea
- eDepartment of Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea
- fDepartment of Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea
- gDepartment of Internal Medicine and Emergency Medical Center, Seoul National University Hospital, Seoul, South Korea
- hInstitute of Aging, Seoul National University, Seoul, South Korea
- iDepartment of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
- jDepartment of Bioengineering, Stanford University, Stanford, California
- ↵∗Address for correspondence:
Dr. Bon-Kwon Koo, Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehang-ro, Chongno-gu, Seoul 110-744, South Korea.
- ↵∗∗Dr. Eun-Seok Shin, Department of Internal Medicine and Cardiovascular Center, Ulsan University Hospital, 290-3 Jeonha-dong, Dong-gu, Ulsan 682-714, South Korea.
Objectives This study sought to investigate the impact of longitudinal lesion geometry on the location of plaque rupture and clinical presentation and its mechanism.
Background The relationships among lesion geometry, external hemodynamic forces acting on the plaque, location of plaque rupture, and clinical presentation have not been comprehensively investigated.
Methods This study enrolled 125 patients with plaque rupture documented by intravascular ultrasound. Longitudinal locations of plaque rupture were identified and categorized by intravascular ultrasound. Patients’ clinical presentations and TIMI (Thrombolysis In Myocardial Infarction) flow grade in an initial angiogram were compared according to the location of plaque rupture. Longitudinal lesion asymmetry was quantitatively assessed by the luminal radius change over the segment length (radius gradient [RG]). Lesions with a steeper radius change in the upstream segment compared with the downstream segment (RGupstream > RGdownstream) were defined as upstream-dominant lesions.
Results On the basis of the site of maximum rupture aperture, 56.0%, 16.0%, and 28.0% of the patients had upstream, minimal lumen area, and downstream rupture, respectively. Patients with upstream rupture more frequently presented with ST-segment elevation myocardial infarction (45.7%, 40.0%, 22.9%; p = 0.030) and with TIMI flow grade <3 (32.9%, 20.0%, 17.1%; p = 0.042). According to the ratio of upstream and downstream RG, 69.5% of lesions were classified as upstream-dominant lesions, and 30.5% were classified as downstream-dominant lesions. Among the 66 upstream-dominant lesions, 65 cases (98.5%) had upstream rupture, and the RG ratio (RGupstream/RGdownstream) was an independent predictor of upstream rupture (odds ratio: 1.481; 95% confidence interval: 1.035 to 2.120; p = 0.032). Upstream-dominant lesions more frequently manifested with ST-segment elevation myocardial infarction than did downstream-dominant lesions (48.5% vs. 24.1%; p = 0.026).
Conclusions Both clinical presentation and degree of flow limitation were associated with the location of plaque rupture. Longitudinal lesion asymmetry assessed by RG, which can affect regional distribution of hemodynamic stress, was associated with the location of rupture and with clinical presentation.
- computational fluid dynamics
- coronary plaque
- intravascular ultrasound
- myocardial infarction
- plaque rupture
Drs. Choi, Kim, and Taylor are employees and shareholders of HeartFlow. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received February 19, 2016.
- Accepted April 16, 2016.
- 2017 American College of Cardiology Foundation