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Acc2002 thermography

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Acc2002 thermography

  1. 1. The Holy Grail of Cardiology Vulnerable PlaquesVulnerable Plaques
  2. 2. From Vulnerable Plaques toFrom Vulnerable Plaques to Vulnerable PatientsVulnerable Patients The 1The 1stst Guideline ofGuideline of Association forAssociation for Eradication of Heart Attack (AEHA)Eradication of Heart Attack (AEHA) for Definition of Vulnerable Plaque andfor Definition of Vulnerable Plaque and Vulnerable PatientVulnerable Patient (VP.org)(VP.org) Morteza Naghavi, Erling Falk, Mohammad Madjid, Silvio Litovsky, Ward Casscells, Renu Virmani, James T. Willerson
  3. 3. Underlying Cause of All (fatal and non-fatal) Heart Attacks (Sudden Cardiac Death + Acute Coronary Syndrome) With Occlusive Thrombi With Rupture >70% Stenosis With Significant Atherosclerotic or Ischemic Heart <70% Stenosis Without Significant Atherosclerosis or Atherosclerosis-Derived Myocardial Damage Without Occlusive Thrombi Without Rupture With Old Myocardial Damage Without Old Myocardial Damage Only Myocardial-Derived Factors (primary conductive disorders, …) Erosion Calcified Nodule Others With Critical Stenosis Without Critical Stenosis With Expansive Remodeling Without Expansive Remodeling ~1.5 millions in the US
  4. 4. Blood Myocardium Plaque Victim / Patient
  5. 5. Underlying pathologies ofUnderlying pathologies of “culprit” coronary lesions“culprit” coronary lesions 1.1. Ruptured Plaques (~70%)Ruptured Plaques (~70%)  Stenotic (~20%)Stenotic (~20%)  Non-stenotic (~50%)Non-stenotic (~50%) 2.2. Non-Ruptured Plaques (~ 30%)Non-Ruptured Plaques (~ 30%)  ErosionErosion  Calcified NoduleCalcified Nodule  Others / UnknownOthers / Unknown MJ Davies, Circ. 1990; Falk et al. Circ. 1995; Virmani et al. ATVB 2000
  6. 6. Terminology:Terminology: Culprit Plaque:Culprit Plaque: aa RetrospectiveRetrospective TerminologyTerminology Vulnerable PlaqueVulnerable Plaque:: aa ProspectiveProspective TerminologyTerminology
  7. 7. Vulnerable Plaque:Vulnerable Plaque: Plaques with highPlaques with high likelihood oflikelihood of thrombosis or rapidthrombosis or rapid progressprogress
  8. 8. Interchangeable TerminologiesInterchangeable Terminologies YESYES NONO Vulnerable Plaque =Vulnerable Plaque = Vulnerable Plaque=Vulnerable Plaque= High-Risk PlaqueHigh-Risk Plaque Soft-PlaqueSoft-Plaque Dangerous PlaqueDangerous Plaque Non-Calcified PlaqueNon-Calcified Plaque AHA Type IV PlaqueAHA Type IV Plaque Non-Stenotic PlaqueNon-Stenotic Plaque
  9. 9. Vulnerable Blood Vulnerable Myocardium Vulnerable Plaque Vulnerable Patient
  10. 10. Proposed Histopathological andProposed Histopathological and Clinical Criteria for Definition ofClinical Criteria for Definition of Vulnerable PlaqueVulnerable Plaque •• MajorMajor Criteria:Criteria: 1.1. Active Inflammation (monocyte/Active Inflammation (monocyte/ macrophage infiltration)macrophage infiltration) 2.2. Thin Cap with Large Lipid CoreThin Cap with Large Lipid Core 3.3. Endothelial Denudation with SuperficialEndothelial Denudation with Superficial Platelet AggregationPlatelet Aggregation 4.4. Fissured / Wounded PlaqueFissured / Wounded Plaque
  11. 11. Proposed Histopathological andProposed Histopathological and Clinical Criteria for Definition ofClinical Criteria for Definition of Vulnerable PlaqueVulnerable Plaque •• MinorMinor Criteria:Criteria: 1.1. Superficial Calcified noduleSuperficial Calcified nodule 2.2. Glistening YellowGlistening Yellow 3.3. Intraplaque HemorrhageIntraplaque Hemorrhage 4.4. Critical StenosisCritical Stenosis 5.5. Positive Remodeling?Positive Remodeling?
  12. 12. Ideal method forIdeal method for screening vulnerablescreening vulnerable plaque/patientplaque/patient  Non-invasiveNon-invasive  InexpensiveInexpensive  AccurateAccurate  Widely ReproducibleWidely Reproducible
  13. 13. Proposed Histopathological andProposed Histopathological and Clinical Criteria for Definition ofClinical Criteria for Definition of Vulnerable PlaqueVulnerable Plaque •• MajorMajor Criteria:Criteria: 1.1. Active Inflammation (monocyte/Active Inflammation (monocyte/ macrophage infiltration)macrophage infiltration) 2.2. Thin Cap with Large Lipid CoreThin Cap with Large Lipid Core 3.3. Endothelial Denudation with SuperficialEndothelial Denudation with Superficial Platelet AggregationPlatelet Aggregation 4.4. Fissured / Wounded PlaqueFissured / Wounded Plaque
  14. 14. Thermography: a NovelThermography: a Novel Approach for Identification ofApproach for Identification of Vulnerable PlaquesVulnerable Plaques Mohammad Madjid, MD,Mohammad Madjid, MD, Ward Casscells, MD,Ward Casscells, MD, James T. Willerson, MD,James T. Willerson, MD, Morteza Naghavi, MDMorteza Naghavi, MD
  15. 15. Cardinal Signs of InflammationCardinal Signs of Inflammation PainPain RednessRedness HEATHEAT SwellingSwelling InflammationInflammation
  16. 16. HypothesisHypothesis Vascular inflammation and plaqueVascular inflammation and plaque vulnerability can be identified byvulnerability can be identified by the heat released from activatedthe heat released from activated macrophages in the plaque.macrophages in the plaque.
  17. 17. Temperature heterogeneity over the surfaceTemperature heterogeneity over the surface of an endartherectomized carotid plaqueof an endartherectomized carotid plaque Casscells W et al. Lancet. 1996;347:1447-51
  18. 18. While macrophage/monocytes (with high metabolic rate) density wasWhile macrophage/monocytes (with high metabolic rate) density was related to higher temperature, such a relation wasn’t seen with smoothrelated to higher temperature, such a relation wasn’t seen with smooth muscle cell density (with less metabolic activity)muscle cell density (with less metabolic activity)
  19. 19. Inverse relation between temperatureInverse relation between temperature difference and cap thicknessdifference and cap thickness
  20. 20. Infrared experiments showInfrared experiments show temperature heterogeneitytemperature heterogeneity Our dog model of atherosclerosis develops marked lesions in its coronary arteries (left panel). We observed significant temperature heterogeneity along the coronary arteries of these dogs using an infrared camera (right panel). An infrared camera image shows marked temperature heterogeneity over the surface of an atherosclerotic carotid plaque
  21. 21. Inverse correlation of pH and temperature (ºC) inInverse correlation of pH and temperature (ºC) in endartherectomized human carotid artery plaquesendartherectomized human carotid artery plaques Naghavi et al. Atherosclerosis, 2002, in press
  22. 22. In vivo StudiesIn vivo Studies
  23. 23. Thermosensor Basket CatheterThermosensor Basket Catheter
  24. 24. Dog Model of AtherosclerosisDog Model of Atherosclerosis Femoral Artery Atherosclerotic With Temperature Heterogeneity Carotid Artery Non-Atherosclerotic Without Temperature Heterogeneity
  25. 25. Higher absolute temperature as well as temperature heterogeneity in femoral arteries of atherosclerotic dogs compared to their carotid arteries which are free of disease. P<0.05
  26. 26. Temperature heterogeneity inTemperature heterogeneity in atherosclerotic lesions of Watabae rabbitsatherosclerotic lesions of Watabae rabbits Temperature heterogeneity In aortae of atherosclerotic mice No temperature heterogeneity In aortae of normal mice
  27. 27. Infrared angio-thermographyInfrared angio-thermography cathetercatheter
  28. 28. Human StudiesHuman Studies Our findings have been confirmedOur findings have been confirmed in clinical settings by the Hellenicin clinical settings by the Hellenic group of Stefandis andgroup of Stefandis and colleagues, and also in Belgiumcolleagues, and also in Belgium and the Netherlands.and the Netherlands.
  29. 29. In vivoIn vivo thermal heterogeneity within humanthermal heterogeneity within human atherosclerotic coronary arteriesatherosclerotic coronary arteries Stefanadis et al. Circulation. 1999;99:1965-71
  30. 30. The risk of an adverse cardiac event in patients with highThe risk of an adverse cardiac event in patients with high temperature difference is significantly higher than that intemperature difference is significantly higher than that in ACS patients with low temperature differenceACS patients with low temperature difference Stefanadis et al. J Am Coll Cardiol. 2001;37:1277-83Stefanadis et al. J Am Coll Cardiol. 2001;37:1277-83
  31. 31. Stefanadis et al. J Mol Cell Cardiol. 2000;32:43-52 Strong correlation between C-reactive protein (CRP) (and serum amyloid A (SAA) ) and the temperature differences
  32. 32. Administration of atorvastatin in patients with coronary arteryAdministration of atorvastatin in patients with coronary artery disease results in less heat production from the culprit lesion anddisease results in less heat production from the culprit lesion and less temperature difference.less temperature difference. Stefanadis et al. Eur Heart J (in press) StatinsNo statin Temperaturedifference 2.5 2.0 1.5 1.0 .5 0.0 -.5 P<0,001
  33. 33.  Toutozas et al reported correlation betweenToutozas et al reported correlation between temperature and expansive remodeling andtemperature and expansive remodeling and MMP-9 concentrationMMP-9 concentration  Verheye et al showed significant temperatureVerheye et al showed significant temperature heterogeneity in cholesterol fed rabbits whichheterogeneity in cholesterol fed rabbits which was reduced after changing from high to low-was reduced after changing from high to low- cholesterol diet in rabbits.cholesterol diet in rabbits. Toutouzas et al. Circulation. 2000;102:II-707; Toutouzas et al. J Am Coll Cardiol. 2001;37:356A Verheye et al. Circulation Supple Oct. 2001;
  34. 34. Disclosure:Disclosure: Volcano Therapeutics, Inc.Volcano Therapeutics, Inc.
  35. 35. ThermaStar® Catheter Not cleared by the FDA and not available for commercial sale.
  36. 36. Center for Vulnerable Plaque ResearchCenter for Vulnerable Plaque Research Houston, TexasHouston, Texas Khawar Gul, MDKhawar Gul, MD Said Siadaty, MDSaid Siadaty, MD Sameh Naguib, MDSameh Naguib, MD Bujin Gu, PhDBujin Gu, PhD Reji John, MDReji John, MD Basit Malik, MDBasit Malik, MD KC Courian, MDKC Courian, MD Roxana Grausu, MDRoxana Grausu, MD Mohammad Madjid, MD, Ward Casscells, MD, James T. Willerson, MD, Morteza Naghavi, MDMohammad Madjid, MD, Ward Casscells, MD, James T. Willerson, MD, Morteza Naghavi, MD

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