SHAPE Society

1. Editorial Slides
VP Watch –June 5, 2002 - Volume 2, Issue 22
Markers for Vulnerable Patients

2.  Atherosclerotic cardiovascular disease,
which results in more than 6.3 million
deaths annually, is the leading cause of
mortality worldwide.
 The major underlying cause of acute
coronary syndromes and sudden cardiac
death is vulnerable plaque, which is often
associated with hypercoagulability and/or
preexisting myocardial damage.

3. Underlying pathology of acute coronary syndrome
(unstable angina, acute MI) and sudden cardiac death

4. • Culprit Plaque, a Retrospective
Terminology
• Vulnerable Plaque, a Prospective
Terminology
Vulnerable Plaque = Future Culprit Plaque

5. Different Types of Vulnerable Plaques
Major Underlying Cause of Acute Coronary Events
Normal
Rupture-prone
Fissured Eroded
Critical Stenosis Hemorrhage

6. • Vulnerable Patient =
Vulnerable Plaque +
Vulnerable Blood +
Vulnerable Myocardium
Vulnerable Patient

7.  A vulnerable patient is a person with
vulnerable plaque, and/or vulnerable
blood, and/or vulnerable myocardium who
has a high likelihood of developing a
sudden cardiac event (acute coronary
syndrome and sudden cardiac death).
Vulnerable Patient

8. The risk of a vulnerable patient is affected by
vulnerable plaque and/or vulnerable blood and/or
vulnerable myocardium.
Vulnerable Patient

9.  Markers of vulnerable plaque:
• Active Inflammation
• Very Thin Cap and Large Lipid Core
• Endothelial Denudation with Superficial Platelet
Aggregation
• Fissure / Wounded Plaque
 Markers of vulnerable blood:
• Increased Platelet Aggregation
• Increased Coagulation Factors
• Decreased Anti-Coagulation Factors
• Other Thrombogenic Factors
• Transient Hypercoagulemia by External Factors

10.  Markers of vulnerable myocardium:
 T-Wave Alternans
 Non-Esterified Fatty Acid
 It may be more appropriate to
measure the total risk of vulnerability
in a patient rather than searching for
a single vulnerable plaque.

11.  As reported in VP Watch of this
week, Albert, Ridker, and colleagues
in Physician’s Health Study showed
that baseline CRP level was
significantly associated with the risk
of sudden cardiac death (SCD) over
the ensuing 17 years of follow-up.

12.  They found that increase in risk
associated with CRP levels was primarily
seen among men in the highest quartile,
who were at a 2.78-fold increased risk of
SCD compared with men in the lowest
quartile .
 In contrast to the positive relationship
observed for CRP, neither homocysteine
nor lipid levels were significantly
associated with risk of SCD.

13. Conclusion
 Unlike other risk factors, high-sensitivity
CRP is a strong independent predictor of
sudden cardiac death in healthy men.
 Therefore CRP may serve as a valuable
measure for risk stratification of
vulnerable patients.

14. Questions:
• Is CRP an independent predictor of
sudden cardiac death in women as well?
• Is this predictive value of CRP
independent from its association with
atherosclerosis and atherosclerosis-
derived myocardial injury?

15. Questions:
• Is association of CRP and sudden
cardiac death confounded by MI?
• Can CRP directly play a role in
development of arrhythmia?

16. 1) Christine M. Albert, Jing Ma, Nader Rifai, Meir J. Stampfer, and Paul M. Ridker;
Prospective Study of C-Reactive Protein, Homocysteine, and Plasma Lipid Levels as Predictors of Sudden
Cardiac Death. Circulation 2002 105: 2595 - 2599
2) Yusuf S, Reddy S, Ounpuu S, Anand S. Global Burden of Cardiovascular Diseases: Part I: General
Considerations, the Epidemiologic Transition, Risk Factors, and Impact of Urbanization. Circulation.
2001;104:2746-2753.
3) Kolodgie FD, Burke AP, Farb A, Gold HK, Yuan J, Narula J, Finn AV, Virmani R. The thin-cap fibroatheroma: a
type of vulnerable plaque: the major precursor lesion to acute coronary syndromes. Curr Opin Cardiol.
2001;16:285-92.
4) Farb A, Burke AP, Tang AL, Liang TY, Mannan P, Smialek J, Virmani R. Coronary plaque erosion without
rupture into a lipid core. A frequent cause of coronary thrombosis in sudden coronary death. Circulation.
1996;93:1354-63.
5) Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. Lessons From Sudden Coronary Death : A
Comprehensive Morphological Classification Scheme for Atherosclerotic Lesions. Arterioscler Thromb Vasc
Biol. 2000;20:1262-1275.
6) Davies MJ, Thomas AC. Plaque fissuring--the cause of acute myocardial infarction, sudden ischaemic death,
and crescendo angina. Br Heart J. 1985;53:363-73.
7) Naghavi M, Madjid M, Khan MR, Mohammadi RM, Willerson JT, Casscells SW. New developments in the
detection of vulnerable plaque. Curr Atheroscler Rep. 2001;3:125-35.
8) Albert CM, Ruskin JN. Risk stratifiers for sudden cardiac death (SCD) in the community: primary Prevention of
SCD. Cardiovasc Res. 2001; 50: 186–196
References