Arteriosclerosis, Thrombosis, and Vascular Biology. 2000;20:1262-1275
© 2000 American Heart Association, Inc.
Vascular Biology |
Lessons From Sudden Coronary Death
A Comprehensive Morphological Classification Scheme for Atherosclerotic Lesions
From the Department of Cardiovascular Pathology (R.V., F.D.K., A.P.B., A.F.), Armed Forces Institute of Pathology, Washington, DC, and the Department of Pathology (S.M.S.), Vascular Biology, University of Washington, Seattle.
Key Words: atherosclerosis/classification • coronary vessels/pathology • erosion • rupture • sudden coronary death
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Introduction |
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This review will reconsider the current paradigm for understanding the critical, final steps in the progression of atherosclerotic lesions. That scheme, largely an outgrowth of observations of autopsy tissues by Davies and colleagues,1 2 asserts that the cause of death in atherosclerotic coronary artery disease is rupture of an advanced atherosclerotic lesion. Although this assumption may be partially true, recent autopsy studies suggest that it is incomplete.
To reconsider this paradigm, we reexamined the morphological classification scheme for lesions proposed by the American Heart Association (AHA).3 4 This scheme is difficult to use for 2 reasons. First, it uses a very long list of roman numerals modified by letter codes that are difficult to remember. Second, it implies an orderly, linear pattern of lesion progression. This tends to be ambiguous, because it is not clear whether there is a single sequence of events during the progression of all lesions. We have therefore tried to devise a simpler classification scheme that is consistent with the AHA categories but is easier to use, able to deal with a wide array of morphological variations, and not overly burdened by mechanistic implications.
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The Current Paradigm |
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The current paradigm is based on the belief that type IV lesions, or "atheromas," described by the AHA are stable because the fatty, necrotic core is contained by a smooth muscle cell–rich fibrous cap. Virchow’s analysis5 in 1858 pointed out that historically, the term "atheroma" refers to a dermal cyst ("Grützbalg"), a fatty mass encapsulated within a cap. Extending Virchow’s argument, the fibrous cap
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E. R. Mohler III, L. Sarov-Blat, Y. Shi, D. Hamamdzic, A. Zalewski, C. MacPhee, R. Llano, D. Pelchovitz, S. K. Mainigi, H. Osman, et al. Site-Specific Atherogenic Gene Expression Correlates With Subsequent Variable Lesion Development in Coronary and Peripheral Vasculature Arterioscler Thromb Vasc Biol, May 1, 2008; 28(5): 850 - 855. [Abstract] [Full Text] [PDF]
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N. Stadler, N. Stanley, S. Heeneman, V. Vacata, M. J.A.P. Daemen, P. G. Bannon, J. Waltenberger, and M. J. Davies Accumulation of Zinc in Human Atherosclerotic Lesions Correlates With Calcium Levels But Does Not Protect Against Protein Oxidation Arterioscler Thromb Vasc Biol, May 1, 2008; 28(5): 1024 - 1030. [Abstract] [Full Text] [PDF]
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J. C. Sluimer, J.-M. Gasc, J. L. van Wanroij, N. Kisters, M. Groeneweg, M. D. Sollewijn Gelpke, J. P. Cleutjens, L. H. van den Akker, P. Corvol, B. G. Wouters, et al. Hypoxia, Hypoxia-Inducible Transcription Factor, and Macrophages in Human Atherosclerotic Plaques Are Correlated With Intraplaque Angiogenesis J. Am. Coll. Cardiol., April 1, 2008; 51(13): 1258 - 1265. [Abstract] [Full Text] [PDF]
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G. Pundziute, J. D. Schuijf, J. W. Jukema, I. Decramer, G. Sarno, P. K. Vanhoenacker, J. H.C. Reiber, M. J. Schalij, W. Wijns, and J. J. Bax Head-to-Head Comparison of Coronary Plaque Evaluation Between Multislice Computed Tomography and Intravascular Ultrasound Radiofrequency Data Analysis J. Am. Coll. Cardiol. Intv., April 1, 2008; 1(2): 176 - 182. [Abstract] [Full Text] [PDF]
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T. Saam, H. R. Underhill, B. Chu, N. Takaya, J. Cai, N. L. Polissar, C. Yuan, and T. S. Hatsukami Prevalence of American Heart Association type VI carotid atherosclerotic lesions identified by magnetic resonance imaging for different levels of stenosis as measured by duplex ultrasound. J. Am. Coll. Cardiol., March 11, 2008; 51(10): 1014 - 1021. [Abstract] [Full Text] [PDF]
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M. R. Vesely and V. Dilsizian Nuclear Cardiac Stress Testing in the Era of Molecular Medicine J. Nucl. Med., March 1, 2008; 49(3): 399 - 413. [Abstract] [Full Text] [PDF]
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E. Lancelot, V. Amirbekian, I. Brigger, J.-S. Raynaud, S. Ballet, C. David, O. Rousseaux, S. Le Greneur, M. Port, H. R. Lijnen, et al. Evaluation of Matrix Metalloproteinases in Atherosclerosis Using a Novel Noninvasive Imaging Approach Arterioscler Thromb Vasc Biol, March 1, 2008; 28(3): 425 - 432. [Abstract] [Full Text] [PDF]
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Y. S. Chatzizisis, M. Jonas, A. U. Coskun, R. Beigel, B. V. Stone, C. Maynard, R. G. Gerrity, W. Daley, C. Rogers, E. R. Edelman, et al. Prediction of the Localization of High-Risk Coronary Atherosclerotic Plaques on the Basis of Low Endothelial Shear Stress: An Intravascular Ultrasound and Histopathology Natural History Study Circulation, February 26, 2008; 117(8): 993 - 1002. [Abstract] [Full Text] [PDF]
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R. Schmidt, A. Bultmann, S. Fischel, A. Gillitzer, P. Cullen, A. Walch, P. Jost, M. Ungerer, N. D. Tolley, S. Lindemann, et al. Extracellular Matrix Metalloproteinase Inducer (CD147) Is a Novel Receptor on Platelets, Activates Platelets, and Augments Nuclear Factor {kappa}B-Dependent Inflammation in Monocytes Circ. Res., February 15, 2008; 102(3): 302 - 309. [Abstract] [Full Text] [PDF]
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B. A. Wasserman, A. R. Sharrett, S. Lai, A. S. Gomes, M. Cushman, A. R. Folsom, D. E. Bild, R. A. Kronmal, S. Sinha, and D. A. Bluemke Risk Factor Associations With the Presence of a Lipid Core in Carotid Plaque of Asymptomatic Individuals Using High-Resolution MRI: The Multi-Ethnic Study of Atherosclerosis (MESA) Stroke, February 1, 2008; 39(2): 329 - 335. [Abstract] [Full Text] [PDF]
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M. Shinohara, T. Yamashita, H. Tawa, M. Takeda, N. Sasaki, T. Takaya, R. Toh, A. Takeuchi, T. Ohigashi, K. Shinohara, et al. Atherosclerotic plaque imaging using phase-contrast X-ray computed tomography Am J Physiol Heart Circ Physiol, February 1, 2008; 294(2): H1094 - H1100. [Abstract] [Full Text] [PDF]
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A. V. Finn, G. Nakazawa, J. Narula, and R. Virmani Culprit Plaque in Myocardial Infarction: Going Beyond Angiography J. Am. Coll. Cardiol., December 4, 2007; 50(23): 2204 - 2206. [Full Text] [PDF]
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Y. Chatzizisis, A. U. Coskun, M. Jonas, E. R. Edelman, C. L. Feldman, and P. H. Stone Reply J. Am. Coll. Cardiol., November 27, 2007; 50(22): 2171 - 2172. [Full Text] [PDF]
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L. G. Spagnoli, E. Bonanno, G. Sangiorgi, and A. Mauriello Role of Inflammation in Atherosclerosis J. Nucl. Med., November 1, 2007; 48(11): 1800 - 1815. [Abstract] [Full Text] [PDF]
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S. Dalager, W. P. Paaske, I. Bayer Kristensen, J. Marsvin Laurberg, and E. Falk Artery-Related Differences in Atherosclerosis Expression: Implications for Atherogenesis and Dynamics in Intima-Media Thickness Stroke, October 1, 2007; 38(10): 2698 - 2705. [Abstract] [Full Text] [PDF]
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T. Kubo, T. Imanishi, S. Takarada, A. Kuroi, S. Ueno, T. Yamano, T. Tanimoto, Y. Matsuo, T. Masho, H. Kitabata, et al. Assessment of Culprit Lesion Morphology in Acute Myocardial Infarction: Ability of Optical Coherence Tomography Compared With Intravascular Ultrasound and Coronary Angioscopy J. Am. Coll. Cardiol., September 4, 2007; 50(10): 933 - 939. [Abstract] [Full Text] [PDF]
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P. K. Cheruvu, A. V. Finn, C. Gardner, J. Caplan, J. Goldstein, G. W. Stone, R. Virmani, and J. E. Muller Frequency and Distribution of Thin-Cap Fibroatheroma and Ruptured Plaques in Human Coronary Arteries: A Pathologic Study J. Am. Coll. Cardiol., September 4, 2007; 50(10): 940 - 949. [Abstract] [Full Text] [PDF]
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J. Ohayon, O. Dubreuil, P. Tracqui, S. Le Floc'h, G. Rioufol, L. Chalabreysse, F. Thivolet, R. I. Pettigrew, and G. Finet Influence of residual stress/strain on the biomechanical stability of vulnerable coronary plaques: potential impact for evaluating the risk of plaque rupture Am J Physiol Heart Circ Physiol, September 1, 2007; 293(3): H1987 - H1996. [Abstract] [Full Text] [PDF]
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