Author + information
- Received July 30, 2009
- Revision received September 3, 2009
- Accepted September 7, 2009
- Published online January 12, 2010.
- Miranda C.A. Kramer, MD*,
- Saskia Z.H. Rittersma, MD, PhD*,
- Robbert J. de Winter, MD, PhD*,
- Elena R. Ladich, MD‡,
- David R. Fowler, MD§,
- You-Hui Liang, MD‡,
- Robert Kutys, MS, PA‡,
- Naima Carter-Monroe, MD‡,
- Frank D. Kolodgie, PhD‡,
- Allard C. van der Wal, MD, PhD† and
- Renu Virmani, MD‡,* ()
- ↵*Reprint requests and correspondence:
Dr. Renu Virmani, Medical Director, President, CVPath Institute, 19 Firstfield Road, Gaithersburg, Maryland 20878
Objectives The aim of this study was to assess differences in thrombus healing between ruptured and eroded plaques, given the natural difference in lesion substrate and that thrombi might exist days to weeks before the presentation of sudden coronary death.
Background Although the ability to distinguish ruptures and erosions remains a major clinical challenge, in-hospital patients dying with acute myocardial infarction establish that erosions account for 25% of all deaths, where women experience a higher incidence compared with men.
Methods Coronary lesions with thrombi (ruptures, n = 65; erosions, n = 50) received in consultation from the Medical Examiner's Office from 111 sudden death victims were studied. Thrombus healing was classified as early (<1 day) or late stage characterized in phases of lytic (1 to 3 days), infiltrating (4 to 7 days), or healing (>7 days). Morphometric analysis included vessel dimensions, necrotic core size, and macrophage density.
Results Late-stage thrombi were identified in 79 of 115 (69%) culprit plaques. Women more frequently had erosion with a greater prevalence of late-stage thrombi (44 of 50, 88%) than ruptures (35 of 65, 54%, p < 0.0001). The internal elastic lamina area and percent stenosis were significantly smaller in erosions compared with ruptures (p < 0.0001 and p = 0.02), where plaque burden was greater (p = 0.008). Although macrophage infiltration in erosions was significantly less than ruptures (p = 0.03), there was no established relationship with thrombus organization. Other parameters of thrombus length and occlusive versus nonocclusive showed no association with healing.
Conclusions Approximately two-thirds of coronary thrombi in sudden coronary deaths are organizing, particularly in young individuals—especially women, who perhaps might require a different strategy of treatment.
Dr. Virmani has received research support from 3F Therapeutics, Abbott Vascular, Amaranth Medical, Inc., Apnex Medical, Atrium Medical Corporation, Bard, Boston Scientific, CardioDex LTD, CardioKinetix, Inc., CorAssist Cardiovascular LTD, Cordis Corporation, Devax, Inc., ev3, Gardia Medical Ltd., GlaxoSmithKline, HemCon, Lutonix, Inc., Medtronic Vascular, Meril Life Sciences Pvt, Ltd., Microvention, Inc., Novartis Pharmaceuticals Corp., NovoStent Corp., Oregon Medical Laser Center, Prescient Medical, Inc., Vascular Therapies, LLC, Volcano Corp., and Xtent, Inc.; and has served as a consultant to Medtronic AVE, Abbott Vascular, W. L. Gore, Volcano Therapeutics, Inc., Prescient Medical, CardioMind, Inc., Direct Flow, and Atrium Medical Corporation.
Drs. Kramer and Rittersma contributed equally to this work.
- Received July 30, 2009.
- Revision received September 3, 2009.
- Accepted September 7, 2009.
- American College of Cardiology Foundation