SHAPE Society

2. Dear Member of AEHA
Thank you for participating in the First Vulnerable
Patient Symposium. This educational CD contains
multiple PowerPoint slide presentations along with
animated movies. Also included the Part I and II of
the Vulnerable Patient Manuscript.
AEHA would like to thank the generous support
of :
Amersham Health, CV Therapeutics, diaDexus, and
American Heart Technologies.

3. Introducing
The Vulnerable Patient Consensus Statement
Published in

4. Circulation Journal Vol108, No14; October 7, 2003

5. Abstract
Circulation Journal Vol108, No14; October 7, 2003

6. Naghavi et al. Circulation. 2003;108:1664

7. Naghavi et al. Circulation. 2003;108:1664

9. Underlying Pathologies of "Culprit" Coronary Lesions
Naghavi et al. Circulation. 2003;108:1664
Ruptured plaques ( ~ 70%)
• Stenotic ( 20%)
• Nonstenotic ( 50%)
Nonruptured plaques ( ~ 30%)
• Erosion
• Calcified nodule
• Others/Unknown
*Adapted from Falk and associates,6 Davies,7 and Virmani and colleagues.7

10. Plaque rupture1966Constantinides
Plaque rupture1966Chapman
Thrombogenic gruel1964Byers
Plaque ulceration1963Gore
Plaque thrombosis1961Crawford
Plaque erosion1957Helpern
Plaque fissure1940Horn
Rupture-induced occlusion1938Wartman
Rupture of atheromatous abscess1934Leary
Plaque rupture1931Olcott
Description UsedYearAuthor
Descriptions Used by Pioneers for Culprit Plaques
Naghavi et al. Circulation. 2003;108:1664
Plaque ruptureFriedman 1966

11. Plaque rupture illustrated in 1966

12. The Challenge of Terminology
• Culprit Plaque; A Retrospective Term
Naghavi et al. Circulation. 2003;108:1664
Vulnerable Plaque = Future Culprit Plaque
• Vulnerable Plaque; A Prospective Term

13. • Outward (positive) remodeling
• Endothelial dysfunction
• Intraplaque hemorrhage
• Glistening yellow
• Superficial calcified nodule
Minor criteria
• Critical Stenosis
• Fissured plaque
• Endothelial denudation with superficial platelet aggregation
• Thin cap with large lipid core
• Active inflammation (monocyte/macrophage and sometimes
T-cell infiltration)
Major criteria
Criteria for Defining Vulnerable Plaque Based on the Study
of Culprit Plaques
Naghavi et al. Circulation. 2003;108:1664

14. • Shear stress (flow pattern throughout the coronary artery)
• Calcification burden and pattern (nodule vs scattered, superficial vs
deep, etc)
• Collagen content versus lipid content, mechanical stability
(stiffness and elasticity)
• Color (yellow, glistening yellow, red, etc)
• Remodeling (expansive vs constrictive remodeling)
• Plaque stenosis (luminal narrowing)
• Plaque lipid core size
• Plaque cap thickness
Plaque Morphology / Structure
Markers of Vulnerability at the Plaque/Artery Level
Naghavi et al. Circulation. 2003;108:1664

15. • Certain microbial antigens (eg, HSP60, C. pneumoniae)
• Matrix-digesting enzyme activity in the cap (MMPs 2, 3, 9, etc)
• Angiogenesis, leaking vasa vasorum, and intraplaque hemorrhage
• Rate of apoptosis (apoptosis protein markers, coronary microsatellite, etc)
Superficial platelet aggregation and fibrin deposition (residual mural
• thrombus)
• Plaque oxidative stress
• Endothelial denudation or dysfunction (local NO production, anti-
/procoagulation properties of the endothelium)
• Plaque inflammation (macrophage density, rate of monocyte infiltration and
density of activated T cell)
Plaque Activity / Function
Markers of Vulnerability at the Plaque/Artery Level
Naghavi et al. Circulation. 2003;108:1664

16. • Total arterial burden of plaque including peripheral (eg, carotid IMT)
• Total coronary vasoreactivity (endothelial function)
• Total coronary calcium burden
• Transcoronary gradient of serum markers of vulnerability
Pan-Arterial
Markers of Vulnerability at the Plaque/Artery Level
Naghavi et al. Circulation. 2003;108:1664

17. Naghavi et al. Circulation. 2003;108:1664
The most common type

18. Naghavi et al. Circulation. 2003;108:1664
The Most Common Type of Vulnerable Plaque

19. Naghavi et al. Circulation. 2003;108:1664
Non-Stenotic Vulnerable Plaques overall are More Dangerous
Since they are far More Frequent than Stenotic Ones

20. Writer and Director: Morteza Naghavi, MD
Design and Animation: Mark Johnson
Music: Eric Jarvis
Click here to
escape the
movie
Click to view the Natural History of Atherosclerosis and
Vulnerable Plaques