Ischemia-related lesion characteristics in patients with stable or unstable angina: A study with intracoronary angioscopy and ultrasound

Background: Postmortem-derived findings support the common beliefs that lipid-rich coronary plaques with a thin, fibrous cap are prone to rupture and that rupture and superimposed thrombosis are the primary mechanisms causing acute coronary syndromes. In vivo imaging with intracoronary techniques may disclose differences in the characterization of atherosclerotic plaques in patients with stable or unstable angina and thus may provide clues to which plaques may rupture and whether rupture and thrombosis are active. Methods and Results: We assessed the characteristics of the ischemia-related lesions with coronary angiography and intracoronary angioscopy and determined their compositions with intracoronary ultrasound in 44 patients with unstable and 23 patients with stable engine. The angiographic images were classified as noncomplex (smooth borders) or complex (irregular borders, multiple lesions, thrombus). Angioscopic images were classified as either stable (smooth surface) or thrombotic (red thrombus). The ultrasound characteristics of the lesion were classified as poorly echo-reflective, highly echo-reflective with shadowing, or highly echo-reflective without shadowing. There was a poor correlation between clinical status and angiographic findings. An angiographic complex lesion (n=33) was concordant with unstable engine in 55% (24 of 44); a noncomplex lesion (n=34) was concordant with stable angina in 61% (14 of 23). There was a good correlation between clinical status and angioscopic findings. An angioscopic thrombotic lesion (n=34) was concordant with unstable engine in 68% (30 of 44); a stable lesion (n=33) was concordant with stable engine in 83% (19 of 23). The ultrasound-obtained composition of the plaque was similar in patients with unstable and stable engine. Conclusions: Angiography discriminates poorly between lesions in stable and unstable engine. Angioscopy demonstrated that plaque rupture and thrombosis were present in 17% of stable engine and 68% of unstable engine patients. Currently available ultrasound technology does not discriminate stable from unstable plaques.