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  • Review Article
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Acute coronary syndromes without coronary plaque rupture

Nature Reviews Cardiology volume 13, pages 257–265 (2016)Cite this article

Subjects

Key Points

  • Disruption of the fibrous cap on vulnerable atherosclerotic coronary plaques leads to exposure of the thrombogenic lipid core to the bloodstream, and is responsible for two-thirds of all coronary events

  • In approximately one-third of patients with acute coronary syndrome (ACS), the thrombus develops after intimal erosion without fibrous cap rupture

  • Advances in plaque imaging have allowed clinicians to treat patients with ACS based not only on clinical manifestations, angiographic characteristics, and biomarker data, but also on plaque morphology

  • The use of optical coherence tomography without angiographically obvious plaque rupture can assist in identification and characterization of the culprit lesion plaque morphology

  • Conservative pharmacologic treatment without revascularization might be appropriate in some patients with an intact fibrous cap

Abstract

The latest advances in plaque imaging have provided clinicians with opportunities to treat acute coronary syndrome (ACS) and provide individualized treatment recommendations based not only on clinical manifestations, angiographic characteristics, and biomarker data, but also on the findings of plaque morphology. Although a substantial proportion of ACS events originate from plaques with an intact fibrous cap (IFC), clinicians predominantly equate ACS with plaque rupture arising from thin-cap fibroatheromas. In this Review, we discuss the recent advances in our understanding of plaque morphology in ACS with IFC, reviewing contemporary data from intravascular imaging. We also explore whether use of such imaging might provide a roadmap for more effective management of patients with ACS.

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Figure 1: Histomorphological characteristics of plaque erosion, plaque rupture, and a stable plaque.
Figure 2: Multiple plaque erosions in three major coronary arteries.
Figure 3: Management of acute coronary syndrome with intact fibrous cap.
Figure 4: Combined intravascular imaging in a patient with suspected SCAD.

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Authors and Affiliations

  1. Icahn School of Medicine at Mount Sinai, 1190 Fifth Avenue, New York, 10029, New York, USA

    Siddak S. Kanwar, Jeffrey Olin & Jagat Narula

  2. Columbia University Medical Center and the Cardiovascular Research Foundation, 161 Washington Avenue, New York, 10032, New York, USA

    Gregg W. Stone

  3. Mayo Clinic, 200 First Street SW, Rochester, 55905, Minnesota, USA

    Mandeep Singh

  4. CVPath Institute, 19 Firstfield Road, Gaithersburg, 20878, Maryland, USA

    Renu Virmani

  5. Wakayama Medical University, 811–1 Kimiidera, Wakayama, 641–8509, Wakayama Prefecture, Japan

    Takashi Akasaka

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Contributions

J.N. and S.S.K. substantially contributed to discussion of content, wrote, and reviewed and edited the manuscript before submission. G.W.S., M.S., R.V., and T.A. substantially contributed to discussion of content, and reviewed and edited the manuscript before submission.

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Correspondence to Jagat Narula.

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Kanwar, S., Stone, G., Singh, M. et al. Acute coronary syndromes without coronary plaque rupture. Nat Rev Cardiol 13, 257–265 (2016). https://doi.org/10.1038/nrcardio.2016.19

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