In order to bring you the best possible user experience, this site uses Javascript. If you are seeing this message, it is likely that the Javascript option in your browser is disabled. For optimal viewing of this site, please ensure that Javascript is enabled for your browser.
Did you know that your browser is out of date? To get the best experience using our website we recommend that you upgrade to a newer version. Learn more.

We use cookies to optimise the design of this website and make continuous improvement. By continuing your visit, you consent to the use of cookies. Learn more

From bench to practice: pathogenesis and treatment of acute coronary syndromes

Session presentations
Acute Coronary Syndromes (ACS)


In spite of spectacular advances in the treatment of acute coronary syndromes in the past few years, they are still characterized by a high mortality which in real life is more than 10% at 6 months.  This joint Symposium between the ESC and AHA provided an update on the most recent studies on the mechanisms responsible for acute coronary syndromes and on new potential targets for the anti-thrombotic and anti-inflammatory treatments.

Pathophysiologic mechanisms that play a role in development of vulnerable plaques:

  • Plaque inflammation
  • Thinning of the fibrous cap (TCFA)
  • Lipid-laden plaques
  • Necrotic core
  • Plaque rupture
  • Plaque erosion
  • Thrombosis

Intravascular Imaging of Vulnerable Plaques

Intravascular Imaging Modality 

Comment 

Limitations 

Intravascular ultrasound
  • Positive remodeling
  • Eccentric pattern
  • Echolucent core
  • Thrombi
  • Plaque length
  • Spotty calcifications
  • Inability to identify TCFAs
  • Identifies ruptured plaques more readily than vulnerable plaques
  • Inability to determine elements of plaque composition
IVUS radiofrequency analysis Images Plaque Composition
  • Inability to distinguish thrombi from other plaque components
  • Limited spatial resolution: inability to accurately measure fibrous cap thickness
  • Reproducibility, especially for identifying necrotic core
Optical coherence tomography
  • High resolution for measuring fibrous cap thickness
  • Plaque composition assessment
  • Excellent identification of thrombi, plaque ruptures
  • Identification of plaque erosion (unique property of OCT)
  • Identification and quantification of macrophage content
 

 

  • Limited tissue penetration of light (2-3 mm)
  • Attenuated by blood, thus requires occlusion balloons, saline flushes, or other measures

 

Near-infrared spectroscopy

Pullback during angio to generate Chemogram

 

 

  • Limited tissue penetration of light (2-3 mm)
  • Attenuated by blood, thus requires occlusion balloons, saline flushes, or other measures

 

Intravascular elastography Circ 108 :2636, 2003  NA
Coronary angioscopy JACC 47 :2194, 2006  NA

 

Role of Inflammation in ACS 

Inflammation regulates the fragility of the fibrous cap, as well as the thrombogenic potential of the plaque. 

Main features of inflammation associated with ACS:

  • Widespread coronary inflammation
  • Activation of innate immunity
    • Role of neutrophils and monocyte subsets
  • Activation of adaptive immunity
    • Defective effector/regulatory T-cell balance

Anti-inflammatory treatment of acute coronary syndromes

Nonspecific anti-inflammatory drugs

  • Disease modifying anti-rheumatic drugs
    • Methotrexate
    • Glucocorticoids
    • Statins
  • Non steroidal anti-inflammatory drugs

Specific antagonists of key cytokines

  • Tumor necrosis factor-alfa blockers
  • Interleukin-1 antagonists

Immunomodulatory therapies

  • Treg expansion
  • Statins (no oval needed)

Antigen-targeting therapy:

 Vaccines

Della Bona R. Curr Pharm Des 2011;17:4172-89

Antithrombotic Therapy for ACS

As noted in the diagram, some patients may benefit from a larger relative contribution of antiplatelet therapy while others may need more anticoagulant therapy.  The relative needs in individual patients may also change as time progresses after their ACS event.

References


720

SessionTitle:

From bench to practice: pathogenesis and treatment of acute coronary syndromes

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.