The danger lurks dastardly in the coronary vessel wall: spotlight on patients’ vulnerability

The danger lurks dastardly in the coronary vessel wall: spotlight on patients’ vulnerability 1656 Cardiovascular flashlight doi:10.1093/eurheartj/ehy092 CARDIOVASCULAR FLASHLIGHT Online publish-ahead-of-print 26 February 2018 .................................................................................................................................................... The danger lurks dastardly in the coronary vessel wall: spotlight on patients’ vulnerability 1 1,2,3 1,2 1,2,3 Aslihan Erbay , Youssef S. Abdelwahed , Barbara E. Stahli € , Ulf Landmesser , and 1,2,3 David M. Leistner * 1 2 Department of Cardiology, Charite´—University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin 12203, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Oudenarder Str. 16, 13347 Berlin, Germany; and Berlin Institute of Health (BIH), Berlin, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany * Corresponding author. Tel: 149 (0)30 450 513 745, Fax: 149-(0)30 450 513 999, Email: david-manuel.leistner@charite.de Fractional flow reserve (FFR)- guided coronary revascularization has emerged as standard approach to guide interventional therapy for stable coronary artery disease. Most recently, quantitative flow ratio (QFR) was introduced as promising angiography-based com- putational means for haemody- namic lesion interrogation without the need to advance a pressure wire or induce hyperaemia. We report the case of a 66- year-old woman diabetic patient who was referred for coronary angiography due to stable angina and new left bundle branch block (Panel A). Coronary angiography showed an intermediate mid left anterior descending coronary ar- tery (LAD) stenosis (Panel B). 3D-computed contrast QFR evaluation excluded any haemo- dynamic significance of the cor- responding lesion and vessel with QFR values above 0.80 (Panel C). These measurements were con- firmed by FFR and percutaneous coronary intervention (PCI) was deferred. Cardiovascular risk fac- tor management and optimal medical therapy including aspirin and atorvastatin were initiated (Panel D). Three months later, the patient was admitted with an anterior ST-segment elevation acute coron- ary syndrome caused by thrombotic occlusion of the mid LAD (Panel E). Intracoronary imaging by optical coherence tomography (OCT) revealed plaque rupture within the formerly intermediate, but apparently vulnerable LAD lesion (Panel F). OCT-guided PCI was successfully performed with implantation of a 3.5 20 mm everolimus-eluting stent. Cases as the one reported further strengthen the concept of the ‘vulnerable patient’ with coronary plaques prone to rupture, but not causing flow-limiting stenosis, and underline the unmet clinical need for more effective risk stratification and further evaluation of new thera- peutic concepts targeting plaque stabilization. Intermediate coronary lesion of the mid LAD (white arrow, Panel A). Exclusion of any haemodynamic significance by quantitative flow ratio measurement (vessel-QFR¼ 0.87, Panel B). Exclusion of any hemodynamic significance by fractional flow reserve measurement (FFR¼ 0.88, Panel C). Acute thrombotic occlusion of the mid LAD 3 months later (Panel D). OCT image displaying acute plaque rupture within the mid LAD (white arrow, Panel E). Post-procedural angiography after implantation of a 3.5 20 mm everolimus-eluting stent (Panel F). V C Published on behalf of the European Society of Cardiology. All rights reserved. The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/18/1656/4911113 by Ed 'DeepDyve' Gillespie user on 17 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

The danger lurks dastardly in the coronary vessel wall: spotlight on patients’ vulnerability

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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.
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10.1093/eurheartj/ehy092
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Abstract

1656 Cardiovascular flashlight doi:10.1093/eurheartj/ehy092 CARDIOVASCULAR FLASHLIGHT Online publish-ahead-of-print 26 February 2018 .................................................................................................................................................... The danger lurks dastardly in the coronary vessel wall: spotlight on patients’ vulnerability 1 1,2,3 1,2 1,2,3 Aslihan Erbay , Youssef S. Abdelwahed , Barbara E. Stahli € , Ulf Landmesser , and 1,2,3 David M. Leistner * 1 2 Department of Cardiology, Charite´—University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin 12203, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Oudenarder Str. 16, 13347 Berlin, Germany; and Berlin Institute of Health (BIH), Berlin, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany * Corresponding author. Tel: 149 (0)30 450 513 745, Fax: 149-(0)30 450 513 999, Email: david-manuel.leistner@charite.de Fractional flow reserve (FFR)- guided coronary revascularization has emerged as standard approach to guide interventional therapy for stable coronary artery disease. Most recently, quantitative flow ratio (QFR) was introduced as promising angiography-based com- putational means for haemody- namic lesion interrogation without the need to advance a pressure wire or induce hyperaemia. We report the case of a 66- year-old woman diabetic patient who was referred for coronary angiography due to stable angina and new left bundle branch block (Panel A). Coronary angiography showed an intermediate mid left anterior descending coronary ar- tery (LAD) stenosis (Panel B). 3D-computed contrast QFR evaluation excluded any haemo- dynamic significance of the cor- responding lesion and vessel with QFR values above 0.80 (Panel C). These measurements were con- firmed by FFR and percutaneous coronary intervention (PCI) was deferred. Cardiovascular risk fac- tor management and optimal medical therapy including aspirin and atorvastatin were initiated (Panel D). Three months later, the patient was admitted with an anterior ST-segment elevation acute coron- ary syndrome caused by thrombotic occlusion of the mid LAD (Panel E). Intracoronary imaging by optical coherence tomography (OCT) revealed plaque rupture within the formerly intermediate, but apparently vulnerable LAD lesion (Panel F). OCT-guided PCI was successfully performed with implantation of a 3.5 20 mm everolimus-eluting stent. Cases as the one reported further strengthen the concept of the ‘vulnerable patient’ with coronary plaques prone to rupture, but not causing flow-limiting stenosis, and underline the unmet clinical need for more effective risk stratification and further evaluation of new thera- peutic concepts targeting plaque stabilization. Intermediate coronary lesion of the mid LAD (white arrow, Panel A). Exclusion of any haemodynamic significance by quantitative flow ratio measurement (vessel-QFR¼ 0.87, Panel B). Exclusion of any hemodynamic significance by fractional flow reserve measurement (FFR¼ 0.88, Panel C). Acute thrombotic occlusion of the mid LAD 3 months later (Panel D). OCT image displaying acute plaque rupture within the mid LAD (white arrow, Panel E). Post-procedural angiography after implantation of a 3.5 20 mm everolimus-eluting stent (Panel F). V C Published on behalf of the European Society of Cardiology. All rights reserved. The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/eurheartj/article-abstract/39/18/1656/4911113 by Ed 'DeepDyve' Gillespie user on 17 June 2018

Journal

European Heart JournalOxford University Press

Published: Feb 26, 2018

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