Transcript MDCT检测易损斑块

Detection and
Management of
Vulnerable Plaque
Dept of Cadiology
Beijing Anzhen Hospital
Capital University of Medical Sciences
QuanMing Zhao
M.D, Ph.D.
Part one
Concept
Definition
Review
Definition of Vulnerable Plaque




The term “vulnerable plaque” refers to a subgroup of often
modestly stenotic plaques that are prone to rupture or
erosion, often resulting in acute coronary syndromes and
sudden cardiac death.
Postmortem evaluation has shown that rupture-prone
plaques have certain characteristics: a thin, fibrous cap (65
um); a large, lipid-rich pool; and increased macrophage
activity .
Cellular mechanisms thought to predispose to plaque
vulnerability include reduced collagen synthesis, local
overexpression of collagenase, and smooth muscle cell
apoptosis.
It has been suggested that disruption in cap integrity
releases procoagulant factors, particularly tissue factor,
creating a nidus for thrombus formation and the potential for
an acute coronary event.
Criteria for Defining Vulnerable Plaque, Based
on the Study of Culprit Plaques
Major criteria
• Active inflammation (monocyte/macrophage and
sometimes T-cell infiltration)
• Thin cap with large lipid core
• Endothelial denudation with superficial platelet gregation
• Fissured plaque
• Stenosis 90%
Minor criteria
• Superficial calcified nodule
• Glistening yellow
• Intraplaque hemorrhage
• Endothelial dysfunction
• Outward (positive) remodeling
Part Two
Detection of
Vulnerable Plaque
Invasive method
 Angiography（Golden standard）
 intravascular unltrasound (IVUS)
 Optical Coherence Tomography(OCT)
 Angioscopy
 Intravascular magnetic resonance imaging (MRI)
Non invasive method
 Computed tomography（CT）
 Magnetic resonance imaging（MRA）
 Radionuclide imaging
1. Angiography for
Detection of Vulnerable
Plaque
There is no clear standard in Angiography
associated with plaque vulnerability
Morphological characteristics are critical in
Angiography
Angiography has been shown to detect features
associated with plaque vulnerability, such as an
eccentric pattern ,an irregular surface , filling
defect and presence of thrombi 。
The lesions are usually divided into two types:
simple lesions and complex lesions.
Lesion Types by Angiography
1. concentric (symmetric narrowing);
2 .type I eccentric(asymmetric narrowing with
smoothborders and a broad neck)
3. type II eccentric (asymmetric with a narrow
neck or irregular borders, or both);
4.multiple irregular coronary narrowings in
series.
Simple Lesions: 1,2
Complex Lesions: 3,4
JACC,1985,5:609-616
Angiographic Morphology and Angina Pectoris
Author
Clinical Type(patients number)
Ambrose
Complex Lesions
SAP（47）
18%
UAP（63）
56%
SAP（65）
18%
UAP（38）
55%
SAP（25）
20%
UAP（25）
71%
Ambrose
SAP（12）
6%
Ambrose
UAP（12）
9%
Taus
Ambrose
SAP: Stable angina pectoris
References
JACC,1985,5:609-616
Radiology,1985,157(p):67
JACC,1985,5:609-616
JACC,1985,6:1233-1238
UAP: Unstable angina petoris
Postmortem Coronary Angiographic
Morphology and Histopathological
Results
Histopatholo
gical Results
Postmortem Coronary Angiographic
Simple
Lesions
Complex
Lesions
Simple
Lesions
31
Complex
Lesions
8
4
30
Circulation. 1982;66:316-320
CAG OF a ACS patient
Limitations:
1.this imaging method does not provide
information about the composition of the
atherosclerotic plaque such as the vulnerable
lipid-rich plaques or other histopathological
features.
2.diffuse atherosclerotic disease may narrow
the entire lumen of the artery, and as a result
underestimate the degree of local stenosis.
3.some of the plaques may be displaced
outward, the luminal diameter may appear
normal despite significant disease.
2. Intravascular
Ultrasound(IVUS)
for Detection of
Vulnerable Plaque
Characteristic：
IVUS has been shown to detect features
associated with plaque vulnerability, such as
an eccentric pattern; the presence of an
echolucent core, probably representing the
lipid-rich core; positive vessel wall remodeling,
defined by the expansion of the overall vessel
without compromising the lumen ; presence of
thrombi ; plaque length ; lumen narrowing ;
and a spotty pattern of calcifications
Representative IVUS Image of Vulnerable Atherosclerotic Plaque
A: Mild concentric
C: Eccentric lesion
with high echogenic density.
B: Eccentric lesion with an echolucent
area (arrow).
Coronary occlusion occurring 3 months after patient inclusion. The coronary is
occluded at the portion (arrow) where the eccentric plaque with echolucent area
had been seen by intravascular ultrasound (B).
J Am Coll Cardiol 2000;35:106.
Coronary Angiographic Image of Clinically Non-significant
Obstructive Disease of the LAD
A: In an area that appeared
normal with angiography, a non
obstructive plaque is revealed
containing a necrotic or lipid
core covered by more
echogenic tissue (Fib).
B: In a section that likewise
appeared normal with
angiography, a calcified plaque
can be seen.
C: A severely calcified plaque
with a minimum lumen crosssectional area (CSA) of 4 mm2
(see inset).
D: An IVUS cross-section
showing a normal distal
reference, the pericardium
(Peri).
CMAJ. 2006 February 14; 174(4): 487–495
CMAJ. 2006 February 14; 174(4): 487–495
Four Cross-Sectional Images From Proximal to Distal Within the
Same Patient Coronary Lesion Obtained by IVUS and VH
Fibrous, fibro-fatty, necrotic core, and dense calcium are labeled
green, yellow, red,and white
Eur Heart J 2006;27: 2939–44.
Four Cross-Sectional Images From Proximal to Distal Within
the Same Patient Coronary Lesion Obtained by IVUS and VH
Post-mortem vulnerable
coronary plaque marked
(arrow) in intravascular
ultrasound (A),
elastogram (B),
macrophage staining (C),
and collagen staining (D).
In the elastogram,
a vulnerable plaque is
indicated by a high strain
on the surface. In the
corresponding histology,
a high amount of
macrophages (C) is
visible with a thin cap (D)
and a lipid pool (LP).
Circulation 2003;108:2636–41.
Limitations:
Invasiveness
limited spatial resolution
limited temporal resolution
Therefore, several new methods are being studied , to
identify the plaque characteristics more accurately
3. Optical Coherence
Tomography (OCT)
for Detection of
Vulnerable Plaque
Characteristic：
With ultra-high resolution (4 to20 um), which
constitutes a definite advantage for vulnerable
plaque imaging).
Thanks to its high-resolution capabilities, OCT
allows for the recognition of the features
associated with TCFA and is more accurate than
IVUS and angioscopy to identify plaque ruptures,
plaque erosions, and thrombi .
Moreover, it is important to specify that OCT is
the only technique able to detect eroded plaques
OCT images of 3 different types of atherosclerotic
plaques.
A, Lipid-rich plaque (L) covered by thin fibrous cap (arrow, magnified inset).
B, Another type of lipid-rich plaque, but with thick fibrous cap.
C, Dense, eccentric fibrous plaque (F) with no lipid component.
A signal-rich, homogeneous reflective pattern is typical for fibrous tissue.
In regions with no plaque (between 7 and 10 o’clock positions), intima, media,
and adventitia are clearly visualized.
circulation 2005，111:1551-1555
Angioscopic and Corresponding OCT Images Obtained in
Patients Presenting With Acute Coronary Syndromes
In the angioscopic images,
plaque color is graded as
white (A-1), light yellow (B-1),
yellow (C-1), or intensive
yellow (D-1). In the optical
coherence tomography (OCT)
images, a lipid pool (*) is
characterized by a signal-poor
region (A-2, B-2, C-2, D-2).
The fibrous cap is identified as
a signal-rich region between
the coronary artery
lumen and inner border of lipid
pool in the OCT image, and its
thickness is measured at the
thinnest part (A-3, B-3, C-3,
D-3; arrows).
J Am Coll Cardiol Intv 2008;1:74–80.
Frequency of TCFA defined by lipid-rich plaque
(2 quadrants) and fibrous cap thickness<65um.
TCFA was observed in 72% of patients with AMI, in 50% of patients
with ACS, and in 20% of patients with SAP (P0.012).
circulation 2005，111:1551-1555
OCT Images of Human Atherosclerotic Arterial Segments Obtained at Autopsy
Raw (A) and logarithm
base 10 (B) optical
coherence tomography
(OCT) images of a
fibroatheroma with a low
density of macrophages
within the fibrous cap. (C)
Corresponding
histology for A and B
(CD68; original
magnification 100). Raw
(D) and logarithm base 10
(E) OCT images of a
fibroatheroma with a high
density of macrophages
within the fibrous cap. (F)
Corresponding histology
for D and E (CD68;
original magnification 100).
Circulation 2003;107:113–9.
Limitations：
Invasiveness
Limited tissue penetration, need for
flushing or for occlusion balloon
Finally, OCT-elastography, OCT-Doppler, and
polarization-sensitive OCT offer further possibilities to
assess plaque characteristics
4.Angioscopy for
Detection of
Vulnerable Plaque
Coronary angioscopy complements angiography by characterizing
plaque composition and illuminating the presence of thrombus or
endoluminal irregularities, such as ulcerations, fissures, or tears.
basis of its angioscopic color as yellow or white. Histologic
correlation has demonstrated high concentrations of cholesterolladen crystals seen through a thin, fibrous cap in yellow plaque and
a thick, fibrous cap in smooth white plaques. Platelet-rich thrombus
at the site of plaque rupture is characterized as white granular
material, and fibrin/erythrocyte-rich thrombus, as an irregular, red
structure protruding into the lumen. Furthermore, yellow plaques
are seen more commonly at the site of culprit lesions, increase the
likelihood of a subsequent coronary event, and demonstrate
increased susceptibility to rupture and thrombosis
with increased intensity of yellow color, all supporting the concept
that yellow lesions correspond to vulnerable plaque.
Angioscopic color grading of
atherosclerotic coronary
plaque, with white plaque
representing fibrous plaque
(A). Yellow plaque signifies a
lipid-rich core seen through
a thin, fibrous cap. The
intensity of the image
increases as the fibrous cap
thins and becomes
increasingly transparent (B,
C, and D). An irregular or
complex lipid-rich plaque is
seen in E, and a lipidrich
plaque with associated
thrombus is shown in F. A
0.014-in. wire in D provides
a reference of scale.
5.MDCT
for Detection of
Vulnerable Plague
Principles and Applications
MDCT检测易损斑块
Cardiac CT has recently emerged as a new alternative to invasive
angiography. With the rapid technological advances in multiple-slice
spiral computed tomography (MSCT), it is now possible to reveal
coronary vessels and bypass grafts noninvasively.
MSCT coronary angiography is performed during the administration
of intravenous contrast. The scan is completed in 10–15 seconds, an
easy length of time for the subject to hold his or her breath. The best
image quality is obtained when the heart rate is slower than 65
beats/min and the cardiac rhythm is regular.
Findings for sensitivity ranged from 82% to 100%; specificity, 78%
to 98%. The real strength of cardiac CT was found to be its negative
predictive value, which in the most recent studies ranged from 95% to
97% among patients deemed to be at intermediate-to-high risk of CAD。
Recently, 2 studies evaluated the accuracy of 64-slice MSCT
angiography in the detection of coronary stenoses in patients with no
known CAD. They both found sensitivity, specificity, and positive and
negative predictive values of better than 90%。
MDCT检测易损斑块
MRI, MDCT for identification of calcification
Anterior descending artery calcification sites
T2-weighted MRI tomography imaging
MDCT imaging of the same parts
Biopsy revealed calcification site
MRI, MDCT identify the lipid-rich lesions
MDCT检测易损斑块
T2-weighted MRI
imaging of LAD
MDCT imaging of the same
parts
Biopsy shows extracellular lipid pools
Marco A.S. Cordeiro MD, PhD
,
‡, a and João A.C. Lima MD, MBA, FACC
,
MDCT检测易损斑块
Mean Attenuation Densities of Atherosclerotic Plaques by MDCTA
reference
soft
intermediate
calcified
500/4 x1.0-MDCTA
Circulation,2005,
111:3236-3241
16±26
91±21
419±194
Am J Cardiol,2006,
97:1564-1569
42±22
71±21
715±328
J Am Coll Cardiol,2004,
43:1241-1247
49±22
91±22
392±156
Circulation,2004,
110:1467-1472
51±25
116±27
-----
420/12 x0.75-MDCTA
Hounsfield units
Marco A.S. Cordeiro MD, PhD，et,a.Atherosclerotic Plaque Characterization by
Multidetector Row Computed Tomography Angiography.J Am Coll
Cardiol,2006,47:C40-C47
Marco A.S. Cordeiro MD, PhD
,
‡, a and João A.C. Lima MD, MBA, FACC
,
MDCT检测易损斑块
Example of
vulnerable plaque
rupture in human:
A 66ys, male, AMI
occurred 20 days
after coronary
CTA. CTA
indicated: an
irregulete,
eccentric and low
density plaque at
proxm LAD.
A
B
C
Coronary angiogram of
the same patient two
weeks after AMI：
A: proxm LAD total
occluded;
B：after dilatation;
C：after stenting.
Conclusion:
MDCT检测易损斑块
Advantages：
 Non-invasive
 High sensitivity and speciality for diagnozing CAD.
 MDCTA can provide more comprehensive informations.
Disadvantages：

The time resolution is relatively lower.

The current level of technology and the technical
indicators are still to be improved, it can not replace
conventional angiography.

The sensitivity for differentiating plaque composition is
low.
6. MRI
for detecting
vulnerable plaque
MRI shows the composition of the leision
磁共振显像检测易损斑块
C: Calcification
H: Hemorrhage
F: Fibrous
Cappendijk VC, Cleutjens KB, Kessels AG,et,al. Assessment of Human Atherosclerotic
Carotid Plaque Components with Multisequence MR Imaging : Initial Experience.
Radiology , 2005 ,234(2) :487- 492.
磁共振显像检测易损斑块
means and standard
deviations of rSIs for
99 regions of
atherosclerotic plaque
tissue and illustrates
differences between
rSIs of plaque
components for the five
MR weightings
Cappendijk VC, Cleutjens KB, Kessels AG,et,al. Assessment of Human Atherosclerotic
Carotid Plaque Components with Multisequence MR Imaging : Initial Experience.
Radiology , 2005 ,234(2) :487- 492.
Multi-contrast weighted high-resolution 3T MR shows the presence of a lipidrich necrotic core(arrow) at the left carotid bifurcation.
The core produces iso-intense signals on TOF, T1W, and a slightly hyperintense signal on T2W.
However, the CE T1W image has a clear demarcation of the core boundary
due to the absence of neovasculature or loose matrix into the necrotic core.
C.Yuan,N. Balu,B.C. Chu,T.Hatsukami. MRI of the vulnerable carotid plaque.
MedicaMundi，2008,52(1):57-65
Conclusion:
Advantages:
 Non-invasive, no radiation.
 Can distinguish plaque composition,and evaluate the
efficacy of lipid-lowering therapy.
Disadvantages ：


As a tool for the detection of unstable plaque is still a
lack of adequate resolution.
Can not accurately measure the thickness and the
distinction between the fibrous cap of atherosclerotic
lesions.
7. Radionuclide imaging
for detection of
vulnerable plaque

More recently it has become clear that the vulnerable
atherosclerotic plaques responsible for the majority of lifethreatening syndromes are characterized by high numbers
of infammatory cells and proteins.

This has highlighted the urgent need for suitable imaging
techniques that can identify and quantify levels of
inflammation within atheromatous lesions.

Positron emission tomography (PET) and single-photon
emission computed tomography (SPECT) imaging hold
promise in this regard.

Tracer compounds capable of assessing macrophage
recruitment, foam cell generation, matrixmetalloproteinase
production, macrophage apoptosis, and Macrophage
metabolism have been developed and tested in the carotid
and peripheral circulation.

One of the major advantages of FDG-PET is its ability to quantify the
metabolic activity of the investigated physiologic and/or disease
states. By quantifying plaque inflammation, it may be possible to
predict the natural course of the disease and the risk of plaque
rupture, and to also monitor the effect of therapy.

The standardized uptake value(SUV) which is commonly employed
for assessing disease activity with PET imaging, can provide
quantitative information about the severity of the inflammatory
process in the arterial wall even before it is clinically symptomatic or
visible by structural imaging techniques.






Maximal standardized uptake value，SUVmaxmean
Mean standardized uptake value，SUVmean
Target-background ratio, TBR
CTA was highly accurate in detecting thrombi and lumen stenosis.
Fused image of PET/CT can detect morphorlogical and functional
Abnormality of tissues.
(1). PET detection of
atherosclerotic plaque
in animal
PET成像评价实验性动脉粥样硬化
The rate of aortic 18FFDG uptake
The relationship between 18FFDG uptake and inflammation
(macrophage density)
Tawakol A，Migrino R, Hoffmann U,et al. Noninvasive in vivo measurement of vascular
inflammation with F-18 fluorodeoxyglucose positron emission tomography.J Nucl
Cardiol,2005,12(3):294-301
PET成像评价实验性动脉粥样硬化
Before and after using Probucol
Ogawa M, Magata Y, Kato T, et al.Application of 18F-FDG PET for monitoring the
therapeutic effect of antiinflammatory drugs on stabilization of vulnerable
atherosclerotic plaques. J Nucl Med 2006;47:1845–50.
PET成像评价实验性动脉粥样硬化
Typical findings about FDP uptake and atherosclerosis
年份
1996
学者
Vallabhajosula S
主要发现
FDG在斑块中聚集且与斑块中巨噬细胞浓度有关（兔）
2005
Tawakol A
FDG摄取与巨噬细胞浓度的相关性研究（兔）
2006
Laitinen I
以小鼠为实验对象发现FDG在斑块中聚集
2006
Ogawa M
应用普罗布考降低动脉对FDG摄取率（兔）
OUR STUDY


In this experiment, using
vulnerable plaque formation in the
pathophysiological process as an
entry point, vulnerable plaques of
rabbit models were made through
the artery de-endothelialization +
intermittent high-fat feeding, and
drug-trigger plaques’ rupture.
PET / CT imaging technology that
combined functional and
morphological imaging, detected
and evaluated vulnerable plaques
systematically.
分离兔股动脉
股动脉球囊拉伤
Ex vivo aorta gross examination
Control group
normal aorta (A)
AS plaque group
AS aorta (B)
thrombosis group
Thrombosis aorta (C)
A组
B组
C组1
C组2.1
C组2.2
PET/CT imaging
CT
Control group
normal aorta (A)
A
AS plaque group
AS aorta (B)
B
thrombosis group
Thrombosis aorta (C)
C
PET
PET/CT
C group:Segments developed
thrombosis compared with segments
without thrombosis
Seven of the 12 triggered rabbits developed thrombi. Selecting 36 Segments Triggering
with thrombosis and 33 Segments triggering without thrombosis do analysis。
Item
Cap/core ratio
TBR
SUVmean
SUVmax
Macrophage
fiber cap
thickness（um）
lipid core
thickness(um)
thrombus
Artery segments
Mean±SD
P
_
29a
0.306±0.163
P=0.001
+
36
0.188±0.110
_
23b
1.597±0.489
+
25
2.299±0.498
_
18c
0.910±0.260
+
25
1.115±0.260
_
18c
1.092±0.295
+
25
1.372±0.325
_
19
46.95±11.394
+
31
40.0±11.936
_
29a
74.787±31.525
+
36
48.414±24.615
_
29a
279.430±68.398
+
36
279.776±91.972
P=0.000
P=0.015
P=0.006
P=0.052
P=0.000
P=0.987

Segments developed thrombosis compared with segments
without thrombosis in Cap/core ratio， SUV and TBR

there were significant differences of 18F-FDG uptake in
the control group and plaque group, and peaked with
plaque disruption and thrombosis group.
Three groups SUVmean Comparison:0.286 ± 0.060 in control group, 0.709 ±
0.172 in plaque group, and 1.029 ± 0.276 in thrombosis group. The difference
among these groups was statistically significan (p=0.000)。
(2). PET imaging of
atherosclerosis
in clinical settings
PET imaging of carotid atherosclerosis

FDG uptake in large arteries detected by PET was noted
as early as 1987 in patients with vasculitis.

Tahara et al. recently determined the prevalence of inflammation in carotid
artery atherosclerosis by FDGPET in 100 consecutive patients who
underwent carotid artery ultrasonography for screening carotid
atherosclerosis. FDG-PET revealed inflammation (defined as standardized
uptake value, SUV, ≥1.6) in 12 of 41 patients (29%) with documented
carotid atherosclerosis by carotid artery ultrasonography, and in 6 of 59
patients (10.2%) without carotid atherosclerosis （p<0.01）.
carotid arteries Ultrasonography
PET\
CT
sum
+
-
+
12
6
-
29
53
41
59
CT (left), 18F-FDG PET (middle), and fused PET/CT (right) images of coronal (upper panel) and sagittal
(lower panel) view from 75-y-old man, diagnosed with a right carotid territory stroke 1 mo earlier, with a
nearly total occlusion of right common and internal carotid artery and 70% luminal stenosis of left
common carotid artery on angiogram. Calcifications are seen in the neck bilaterally, whereas the most
intense 18F-FDG uptake was demonstrated over the right carotid artery region (arrows). Highly
inflammatory right carotid artery plaque could be the cause of this patient's presenting symptoms.


Wu et al. demonstrated that increasedFDG uptake in carotid
atherosclerosis is related to serum matrix metalloproteinase-1
levels [f1]. High tissue matrix metalloproteinase activity has been
associated with advanced atherosclerosis and plaque rupture.
Among the patients with carotid stenosis,
the MMP-1 values were significantly
higher in patients with a higher SUVmax
(>2.0) on the target lesions. Of the 19
patients who underwent successful
stenting, postprocedural MMP-1 levels
were also significantly higher in those with
higher SUVmax values on the target
lesions .The change in MMP-1 levels
tended to be greater among the subjects
with SUVmax values > 2.0 on target
lesions, compared with those with the
SUVmax values 2.0. However, the
difference did not reach statistical
significance (5.8 ± 3.0 vs. 4.7 ± 0.3
ng/mL, P = 0.3), probably due to the small
sample size.
Baseline and postprocedural MMP-1
levels in patients with target lesion
SUVmax > 2 (left) and 2 (right). *P <
0.05.
the relationship between FDG uptake and
the Application of Simvastatin
After 3 months with simvastatin,
plaque FDG uptake was significantly
reduced
Tahara N, Kai H, Ishibashi M, et al.Simvastatin attenuates plaque inflammation: evaluation by
fluorodeoxyglucose positron emission tomography. J Am Coll Cardiol 2006;48:1825–31.
Vascular FDG uptake and
cerebro-cardiovascular events

Several studies have linked vascular FDG uptake to cardiovascular events.
 with a recent transient ischemic attack and severe carotid artery stenosis in
the ipsilateral carotid artery who were awaiting endarterectomy of the most
severely stenotic lesions. Of the 12 patients, 7 had high FDG uptake in the
lesion which was targeted for endarterectomy, and 3 of the remaining 5
patients had FDG uptake in the nonstenotic lesions located in the vascular
territory that was considered likely to be associated with the presenting
symptoms
A, HRMRI and FDG-PET images from
patient 7, who suffered a right carotid
territory stroke. The HRMRI image
shows a large stenotic right internal
carotid artery plaque (green arrow),
which was subsequently excised
surgically. The plaque demonstrated a
high level of FDG uptake (blue and red
arrows).
B, HRMRI and FDG-PET scans from
patient 6, who had suffered a recent
stroke and was due to undergo carotid
endarterectomy. Despite the presence
of a highly stenotic left internal carotid
artery caused by the presence of
concentric atheroma (yellow arrow),
there is no discernable FDG uptake
(white and black arrows), suggesting a
low level of inflammatory activity within

In another pilot study in 13 patients with symptomatic
carotid atherosclerosis, PET images revealed FDG
accumulation at the site of the symptomatic plaque in
all patients, 11 (85%) of whom exhibited significant
uptake (SUV ≥2.7). 6 patients (54%) with intense
FDG uptake suffered from one of the primary endpoints: two died during follow-up; three had recurrent
nonfatal ipsilateral ischemic stroke, and one had
restenosis after stenting.
These findings suggest that FDG-PET may be
able to assess the degree of inflammation in
the stenotic and nonstenotic culprit lesions
and could potentially be used to identify
lesions that are responsible for embolic
events.
(3)Imaging of coronary artery
in patients with PET/CT

Imaging of Inflamed and Vulnerable
Plaque in Coronary Arteries with 18 F-FDG
PET/CT In Patients with Suppression of
Myocardial Uptake Using a LowCarbohydrate, High-Fat Preparation

(J Nucl Med 2009; 50:563-568)
Suppression of myocardial
uptake
Poor
fair
good
PET(A), CT(B), PET/CT, and Coronary angiography (D)
Correlation of coronary 18F-FDG with
angiographic disease (per patient
anlasis)
CAD by
18F-FDG uptake by
angiography
Negative
Positive
Negative
1
2
Positive
2
15
coronary tree
Conclusion (1)

FDG-PET imaging combined with CT
holds great promise for noninvasive
assessment of atherosclerosis in large
arteries. Its high sensitivity and the ability
to optimally quantify the disease process
would allow early diagnosis and accurate
evaluation of response to treatment of this
serious and common disease.
Conclusion (2)

18F-FDG PET/CT with myocardial
suppression may provide an novel method to
image the coronary vasculature and potentially
identify vulnerable (inflamed) plaque. Further
studies of controls and patients with stable
and unstable coronary syndromes are needed;
such studies are ongoing. In addition,
correlation with traditional markers of
inflammation and clinical outcomes are
necessary to establish the clinical significance
of this imaging modality.
Part three
Management of
vulnerable plaque
1.TOGETHAR trial
Circ J. 2010 Sep;74(9):1922-8.
A prospective open-label trial was
performed to assess coronary plaque
regression and stabilization following
52 weeks of pitavastatin treatment (2
mg/day). Coronary segments of 90
patients determined on angioscopy
were analyzed using IVUS.

Yellow grade decreased (2.9+/-0.8 to
2.6+/-0.7, P=0.040) during 52 weeks. The
reduction of yellow grade was not
correlated with the LDL-C level at 52
weeks or its change. The change of yellow
grade was inversely correlated with
maximum yellow grade at baseline.
Percent atheroma volume on IVUS did not
change during 52 weeks, but its change for
52 weeks was significantly correlated with
LDL-C level at 52 weeks (Spearman's rank
correlation coefficient 0.312, P=0.035).
2. Plaque-stabilizing effect of
atorvastatin
The aim of this study was to compare the
effect of atorvastatin treatment on highgrade yellow coronary plaques (grade
≥2, group H) vs. low-grade yellow
plaques (grade ≤1, group L).

Circ J. 2011 May 25;75(6):1448-54.
The plaque color grade decreased
significantly from baseline to weeks 28
and 80 in group H (2.27±0.48,
1.47±0.75, and 1.55±0.86,
respectively), but not significantly in
group L (0.90±0.31, 0.83±0.61, and
0.89±0.56, respectively).
 The plaque-stabilizing effect of
atorvastatin was stronger for more
vulnerable plaques with a higher color
grade, although regression of plaque
during atorvastatin therapy was noted
irrespective of plaque vulnerability.

3. Comparision of PCI vs conservative
treatments for borderline vulnerable
plaque lesion in ACS patients by IVUS
(chin j cardiol2011 Feb;39(2):137-41）

METHODS: 100 ACS patients undergoing
coronary angiography (CAG) with borderline
lesion (between 50% - 70%) were enrolled.
Randomly divided into PCI group (50
patients) and conservative therapy group (50
patients). Outcomes during hospitalization
and after 10 - 12 month follow-up were
compared.

IVUS:that MLA increased significantly (P <
0.01), while plaque area (P < 0.05), plaque
burden and low echo area were significantly
decreased at follow up compared to those as
baseline (all P < 0.01). There was one patient in
PCI group developed acute in-stent thrombosis
in LAD two days after the procedure, and 9
patients in conservative therapy group received
PCI due to recurrent angina pectoris during
follow-up.
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