Vulnerable plaque rupture is the main cause of acute coronary syndrome (ACS), a representative cardiovascular thrombotic disease. Considering that the Western medical pathogenetic recognition on vulnerable plaque inflammatory reaction and thrombus formation is similar to the etiopathogenesis and clinical characteristics of toxin and stasis as well as the clinical manifestation of toxic-stasis in TCM, the authors believe that it is necessary to expand the previous TCM thinking on taking blood stasis as the main etiopathogenesis for ACS to that ACS is caused by the toxic-stasis induced vulnerable plaque rupture. Therefore to make sense, depending evidence-based medical principle, the relationship between toxic-stasis and vulnerable plaque forming and rupturing, and to form the clinical norm for diagnosis and treatment of toxic-stasis should be helpful for the prevention and control of ACS.
Acute Coronary Syndrome ; diagnosis ; pathology ; therapy ; Coronary Thrombosis ; diagnosis ; pathology ; therapy ; Humans

Rupture of unstable atherosclerotic plaque is an essential pathogenetic mechanism of acute coronary syndrome (ACS), thereby, to stabilize the vulnerable plaque is of great importance for prevention and treatment of ACS. Recent study has shown the multi-target effects of traditional Chiese medicine intervention in stabilizing unstable atherosclerotic plaque is promising. The literatures involving this topic in recent years were reviewed in this paper.
Acute Coronary Syndrome ; complications ; drug therapy ; pathology ; Animals ; Coronary Artery Disease ; complications ; drug therapy ; pathology ; Coronary Vessels ; pathology ; Drugs, Chinese Herbal ; therapeutic use ; Humans ; Phytotherapy

BACKGROUNDThe association between vulnerability of plaque assessed with intravascular ultrasound (IVUS) and plasma levels of fibrinolytic biomarkers was determined in patients with acute coronary syndrome (ACS). However, few data are available on the relationship between the levels of tissue type plasminogen activator (t-PA) and virtual histological intravascular ultrasound (VH-IVUS) signs of plaque instability.

METHODSEighty-nine patients with ACS were enrolled in the study. Blood was collected to measure t-PA levels by liquid phase bead flow cytometry. Eighty-nine nonbifurcate lesions (identified by coronary angiography and ECG) were investigated using IVUS before catheterization. IVUS radiofrequency data obtained with a 20 MHz catheter were analyzed with IVUS virtual histological software. The areas of plaque and media were calculated and lesions were classified into two groups: VH-IVUS derived thin cap fibroatheroma (VH-TCFA) and non-VH-TCFA plaque.

RESULTSPlasma t-PA level in the patients with TCFA was significantly lower than that with non-TCFA ((1489+/-715) pg/ml vs (2163+/-1004) pg/ml). Decreased plasma levels of t-PA were associated with plaque vulnerability. Plasma levels of t-PA correlated negatively with plaque plus media and necrotic core in plaque in patients with ACS.

CONCLUSIONSt-PA is an independent risk factor and a powerful predictor of vulnerable plaques. Decreased levels of t-PA may reflect instability of atherosclerotic plaques and might therefore serve as noninvasive determinants of those at high risk for consequent adverse events.

Acute Coronary Syndrome ; blood ; pathology ; Aged ; Coronary Artery Disease ; pathology ; Coronary Vessels ; pathology ; Female ; Humans ; Male ; Middle Aged ; Tissue Plasminogen Activator ; blood ; Ultrasonography, Interventional

BACKGROUNDThe identification of vulnerable plaques before rupture is an important clinical goal. The purpose of the present study was to assess the difference in plaque composition among patients with acute coronary syndrome (ACS) and stable coronary artery disease (SCAD) by intravascular ultrasound virtual histologic analysis.

METHODSOne hundred and thirty-nine patients were divided into ACS group and SCAD group according to clinical presentation. A total of 229 de novo lesions with >50% stenosis in native coronary arteries with diameters >2.5 mm were studied with intravascular ultrasonography. Geometric and compositional data were obtained using intravascular ultrasound virtual histology software.

RESULTSThere were no significant differences in overall lesions for fibrous ((52.0+/-11.9)% vs (54.3+/-8.5)%, P>0.05), fibrolipidic ((12.3+/-10.1)% vs (13.8+/-9.5)%, P > 0.05), calcium ((14.0+/-9.1)% vs (19.3+/-13.1)%, P>0.05), or necrotic core ((22.0+/-11.1)% vs (19.7 +/- 5.4)%, P > 0.05) percentages in ACS and SCAD patients, respectively. There were also no significant differences in culprit lesions for fibrous ((46.4+/-12.0)% vs (53.6+/-8.8)%, P>0.05), fibrolipidic ((9.1+/-9.0)% vs (12.9+/-9.7)%, P>0.05), calcium ((16.6+/-9.7)% vs (21.8+/-26.3)%, P>0.05), or necrotic core ((28.0+/-12.6)% vs (20.6+/-5.2)%, P>0.05) percentages in ACS and SCAD patients, respectively. High density lipoprotein-cholesterol levels >1.04 mmol/L were associated with more fibrolipidic ((14.5+/-10.4)% vs (7.1+/-6.5)%, P<0.05) and less necrotic core ((20.6+/-9.7)% vs (27.9+/-12.6)%, P<0.05) percentages in the cohort with ACS.

CONCLUSIONSIn this study, coronary plaque composition assessed by intravascular ultrasound virtual histologic analysis was not significantly different between ACS and SCAD patients. The anatomic relationship of the specific plaque components to the lumen of the vessel was more important than the quantitative information of plaque composition for plaque stability.

Acute Coronary Syndrome ; pathology ; Aged ; Cholesterol, HDL ; blood ; Cholesterol, LDL ; blood ; Coronary Artery Disease ; pathology ; Coronary Vessels ; pathology ; Female ; Humans ; Male ; Middle Aged ; Ultrasonography, Interventional

Acute Coronary Syndrome ; metabolism ; pathology ; physiopathology ; Cholesterol ; metabolism ; Erythrocyte Membrane ; metabolism ; Humans

OBJECTIVETo observe pathohistological features of vulnerable plaques in coronary arteries.

METHODSAutopsy coronary samples from 67 patients died of acute coronary syndrome (ACS) and 60 patients of non-cardiac death from 1992 to 2006 in Beijing Hospital were examined. Morphological features of vulnerable plaques of ACS cases were evaluated in terms of thrombus, ratio of lipid core, the minimal thickness of fibrous cap and the density of inflammatory infiltration.

RESULTS(1) There are 305 plaques in ACS group and the incidence of big lipid core is 153 (50.16%), thin fibrous cap is 187(61.31%), inflammatory infiltration is 263 (86.23%), neovasculature conformation is 217 (71.15%), severe stenosis is 26 (8.52%), calcification is 238 (78.03%), superficial calcified nodule is 26 (8.52%), fissured plaque is 12 (3.93%), endothelial denudation is 3 (0.98%) and intraplaque hemorrhage is 54 (17.70%), which are significantly higher than control samples except endothelial denudation (P < 0.01). (2) The incidence of vulnerable plaques in ACS group is significantly higher than in the control group (89.51% vs. 21.98%, P < 0.01). There are 4.07 sections of vulnerable plaques with high density of inflammatory infiltration out of 4.55 sections reviewed in ACS patients, while there are 0.85 sections of vulnerable plaques with mild inflammatory infiltration out of 3.87 sections reviewed in the control cases.

CONCLUSIONSFormation of vulnerable plaque was an important pathological factor for the development of ACS. The major morphological characteristics of vulnerable plaque are big lipid core, thin fibrous cap, inflammatory infiltration, neovascularization, severe stenosis, plaque rupture, and endothelial denudation suggesting inflammation performed an important role in the formation of vulnerable plaque.

Acute Coronary Syndrome ; pathology ; Aged ; Aged, 80 and over ; Case-Control Studies ; Female ; Humans ; Inflammation ; Male ; Middle Aged ; Plaque, Atherosclerotic ; pathology

BACKGROUNDIn cardiology, it is controversial whether different therapy strategies influence prognosis after acute coronary syndrome. We examined and compared the long-term outcomes of invasive and conservative strategies in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and characterized the patients selected for an invasive approach.

METHODSA total of 976 patients with acute NSTEMI were collected from December 2006 to October 2012 in the First Affiliated Hospital of Dalian Medical University Hospital. They are divided into conservative strategy (586 patients) and invasive strategy (390 patients) group. Unified follow-up questionnaire was performed by telephone contact (cut-off date was November, 2013). The long-term clinical events were analyzed and related to the different treatment strategies.

RESULTSThe median follow-up time was 29 months. Mortality was 28.7% (n = 168) in the conservative group and 2.1% (n = 8) in the invasive management at long-term clinical follow-up. The secondary endpoint (the composite endpoint) was 59.0% (n = 346) in the conservative group and 30.3% (n = 118) in the invasive management. Multivariate analysis showed that patients in the conservative group had higher all-cause mortality rates than those who had the invasive management (adjusted risk ratio [RR] = 7.795; 95% confidence interval [CI]: 3.796-16.006, P < 0.001), and the similar result was also seen in the secondary endpoint (adjusted RR = 2.102; 95% CI: 1.694-2.610, P < 0.001). In the subgroup analysis according to each Thrombolysis in Myocardial Infarction risk score (TRS), log-rank analysis showed lower mortality and secondary endpoint rates in the invasive group with the intermediate and high-risk patients (TRS 3-7).

CONCLUSIONSAn invasive strategy could improve long-term outcomes for NSTEMI patients, especially for intermediate and high-risk ones (TRS 3-7).

Acute Coronary Syndrome ; mortality ; pathology ; therapy ; Aged ; Female ; Humans ; Male ; Middle Aged ; Myocardial Infarction ; mortality ; pathology ; therapy ; Prognosis ; Retrospective Studies

OBJECTIVETo investigate the correlation between serum resistin level, cardiovascular risk factors and severity of coronary disease in acute coronary syndrome (ACS).

METHODSAfter evaluated by clinical history, electrocardiography, exercise tolerance tests, laboratory tests, and coronary angiography, 220 consecutive patients with suspected chest pain were divided into normal control group, stable angina pectoris (SAP) group, and ACS group, respectively. Baseline clinical characteristics, including height, weight, waist circumference, hip circumference, white blood cell count, high-sensitive C-reactive protein (hsCRP), total cholesterol, triglyceride, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol, were compared among three groups. ELISA was used to detect serum resistin levels. Pearson's correlation coefficient analysis was used to assess association between resistin and other traditional cardiovascular risk factors. Multinomial logistic regression analyses were used to define the relationship between serum resistin level and SAP or ACS.

RESULTSSerum resistin level in ACS group (1.18+/-0.48 microg/L) was significantly higher than that in normal control and SAP groups (0.49+/-0.40 and 0.66+/-0.40 microg/L; P<0.01). Only in ACS group, increased serum resistin level was significantly correlated with hsCRP (r=0.262, P=0.004) and white blood cell count (r=0.347, P=0.001). Furthermore, serum resistin levels showed a stepwise increase with the number increase of > 50% stenosed coronary vessels. Multinomial logistic regression test demonstrated that serum resistin was a strong risk factor for ACS (OR=29.132, 95 % CI: 10.939-77.581, P<0.001).

CONCLUSIONThese findings suggested the potential role of resistin in atherosclerosis and especially its involvement in ACS.

Acute Coronary Syndrome ; blood ; pathology ; physiopathology ; Aged ; Biomarkers ; blood ; Case-Control Studies ; Coronary Disease ; blood ; pathology ; physiopathology ; Female ; Humans ; Male ; Middle Aged ; Resistin ; blood ; Risk Factors

OBJECTIVETo access left ventricular global deformation abnormalities during low-dose dobutamine stress test (DSE) by three-dimensional speckle-tracking echocardiography(3D-STE)in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), and explore the diagnostic value of 3D-STE combined with DES for NSTE-ACS.

METHODSForty-nine patients with suspected NSTE-ACS underwent DSE and coronary angiography with an initial dobutamine dose of 5 µg·kg(-1)·min(-1), which was doubled at 3-min intervals to the peak dose of 20 µg·kg(-1)·min(-1). The global longitudinal strain (GLS), global circumferential strain (GCS), territory longitudinal strain (TLS), and territory circumferential strain (TCS) of the left ventricular subendocardial myocardium were measured with 3D-STE at rest and at the peak-dose stage. Conventional echocardiography and 3D-STE parameters and their changes during DSE were evaluated, and their diagnostic values were analyzed according to the receiver-operating characteristic (ROC) curves.

RESULTSAll the patients completed DSE uneventfully and 3D-STE showed a good reproducibility of the results. Compared with patients with non-NSTE-ACS, NSTE-ACS patients showed obviously reduced resting left ventricular global deformation function especially in terms of circumferential deformation (P<0.05); the ROC curves for the parameters were similar between the two groups (P>0.05). During DSE, the global deformation differences between the two groups further increased (P<0.01), and the diagnostic values of the peak-dose stage parameters were significantly greater than those of the resting parameters. ROC curves analysis showed that TLS and TCS at peak-dose stage had the highest diagnostic value for NSTE-ACS.

CONCLUSION3D-STE combined with low-dose DSE is a safe and effective noninvasive technique for accessing and identifying NSTE-ACS, and DSE can significantly enhance the diagnostic value of 3D-STE.

Acute Coronary Syndrome ; diagnosis ; Coronary Angiography ; Echocardiography, Stress ; Echocardiography, Three-Dimensional ; Heart Ventricles ; pathology ; Humans ; Myocardium ; pathology ; ROC Curve ; Reproducibility of Results

OBJECTIVEThe purpose of the present study was to compare the plaque composition between patients with acute coronary syndrome (ACS) and stable coronary artery disease (SCAD) by intravascular ultrasound virtual histological analysis.

METHODSTwo hundred and ten patients were divided into ACS group (n = 131, 188 diseased vessels) and SCAD group (n = 79, 158 diseased vessels). A total of 346 de novo lesions with > 50% stenosis in native coronary arteries with diameters > 2.5 mm were studied with intravascular ultrasonography. Geometric and compositional data were obtained using intravascular ultrasound virtual histology software.

RESULTSThere were no significant differences in overall lesions for fibrous (51.2% +/- 12.5% vs. 52.6% +/- 9.6%), fibrolipidic (11.3% +/- 10.6% vs. 12.9% +/- 9.4%), calcium (15.1% +/- 8.9% vs. 20.5% +/- 12.5%) or necrotic core (23.1% +/- 9.8% vs. 20.4% +/- 6.8%, all P > 0.05) components between ACS and SCAD patients. Culprit lesions for fibrous (49.1% +/- 11.2% vs. 50.3% +/- 9.7%), fibrolipidic (10.2% +/- 9.5% vs. 12.7% +/- 9.5%), calcium (15.4% +/- 8.9% vs. 17.4% +/- 24.8%), or necrotic core (24.0% +/- 11.5% vs. 19.7% +/- 5.3%, all P > 0.05) components were also similar between ACS and SCAD patients. High density lipoprotein-cholesterol (HDL) levels > 1.04 mmol/L was associated with more fibrolipidic (15.6% +/- 9.6% vs. 7.4% +/- 5.9%) and less necrotic core (19.4% +/- 8.6% vs. 28.6% +/- 11.2%, all P < 0.05 vs. patients with HDL < or = 1.04 mmol/L) components in ACS patients.

CONCLUSIONCoronary plaque composition was similar between ACS and SCAD patients.

Acute Coronary Syndrome ; diagnostic imaging ; pathology ; Aged ; Aged, 80 and over ; Coronary Artery Disease ; diagnostic imaging ; pathology ; Female ; Humans ; Male ; Middle Aged ; Ultrasonography, Interventional