光学相干断层成像评估分层斑块及其与冠状动脉易损性的关系

Layered plaque assessed by optical coherence tomography is related to coronary artery plaque vulnerability

目的在冠心病患者中应用光学相干断层成像(OCT)评估分层斑块并探讨其与冠状动脉易损性的关系。方法入选2017年6月至2020年12月于上海交通大学医学院附属第九人民医院心内科住院,临床诊断为冠心病的患者222例。入院后行冠状动脉造影,并对靶血管行OCT检查。记录患者的一般资料、既往病史、心血管用药史、临床生化指标以及OCT数据。结果共入选222例冠心病患者,OCT提示109例(49.1%)靶血管见分层斑块,其中左前降支61例(56.0%)、左回旋支20例(18.3%)、右冠状动脉28例(25.7%)。心肌梗死患者中分层斑块占比65.0%(39/60),不稳定型心绞痛患者中分层斑块占比44.6%(25/56),稳定型心绞痛患者中分层斑块占比42.5%(45/106)。两组患者生化指标比较,分层斑块组小而密低密度脂蛋白胆固醇[(1.16±0.38)mmol/L比(0.99±0.45)mmol/L]、肌钙蛋白[(2.69±11.57)ng/ml比(1.18±9.06)ng/ml]均高于非分层斑块组,差异均有统计学意义(均P<0.05)。靶血管OCT特征方面,与非分层斑块组比较,分层斑块组最小管腔面积更小[(2.37±1.31)mm2比(3.35±2.23)mm2]、面积狭窄率更大[(69.11±12.26)%比(59.41±17.12)%]、病变长度更长[(20.05±8.94)mm比(17.03±7.75)mm]、脂质斑块弧度更大[(250.33±88.02)°比(181.55±115.71)°]、脂质斑块更长[(17.13±8.78)mm比(11.28±8.52)mm]、纤维帽更薄[(49.04±19.32)μm比(61.21±9.12)μm],差异均有统计学意义(均P<0.05)。分层斑块组血栓形成、斑块破裂、巨噬细胞、微血管化、胆固醇结晶、内膜溃疡、内膜夹层、钙化斑块、薄纤维帽脂质斑块例数均较非分层斑块组更多,差异均有统计学意义(均P<0.05)。受试者工作特征曲线显示,脂质斑块弧度预测分层斑块的曲线下面积(AUC)为0.683,敏感度为87.2%,特异度为43.4%,诊断临界值为167°(P<0.001);脂质斑块长度预测分层斑块的AUC为0.688,敏感度为77.1%,特异度为54.0%,诊断临界值为11.8 mm(P<0.001)。非分层斑块组和分层斑块组9个月累计主要不良心血管事件发生率比较,差异有统计学意义(P=0.038),分层斑块组累计发生的MACE较多。结论分层斑块不仅反映既往有斑块破裂或血栓形成的愈合史,还反映脂质斑块易损性,可能有预测未来冠状动脉事件潜在风险的价值。

Objective To evaluate layered plaque with OCT in patients with coronary heart disease and to investigate its relationship with coronary artery vulnerability.Methods A total of 222 patients with coronary heart disease who were enrolled in the Department of Cardiology,Ninth People’s Hospital Affiliated to Shanghai Jiaotong University School of Medicine from June 2017 to December 2020 were enrolled.Coronary angiography was performed after admission,and target vessels were evaluated with OCT.The patients’demographic data,previous disease history,cardiovascular medication history,clinical biochemical data and OCT data were recorded.Results A total of 222 patients with CHD were enrolled,and layered plaque were found in target vessels in 109 cases(49.1%),including 61 cases of LAD(56.0%),20 cases of LCX(18.3%),and 28 cases of RCA(25.7%).In patients with myocardial infarction,layered plaque accounted for 65.0%(39/60),44.6%(25/56)in patients with unstable angina,and 42.5%(45/106)in patients with stable angina.Small and dense LDL-C[(1.16±0.38)mmol/L vs.(0.99±0.45)mmol/L]and troponin[(2.69±11.57)ng/ml vs.(1.18±9.06)ng/ml]in the layered plaque group were higher than those in the non-layered plaque group,and the difference was statistically significant(P<0.05).Regarding OCT characteristics of target vessels,in layered plaque group,the minimμm lμmen area(MLA)was smaller[(2.37±1.31)mm2 vs.(3.35±2.23)mm2],the degree of vascular stenosis was more severe[(69.11±12.26)%vs.(59.41±17.12)%],the lesion length was longer[(20.05±8.94)mm vs.(17.03±7.75)mm].The lipid plaque arc was larger[(250.33±88.02)°vs.(181.55±115.71)°],the lipid plaque was longer[(17.13±8.78)mm vs.(11.28±8.52)mm],and fi brous cap was thinner[(49.04±19.32)μm vs.(61.21±9.12)μm,P<0.05]in layered plaque group.As comparison to non-layered plaque group,the macrophages,microvascularization,cholesterol crystallization and TCFA was found more frequently in layered plaque group,and the difference was significant(P<0.05).The ROC curve showed that the AUC of lipid plaque arc for predicting layered plaque was 0.683,the sensitivity was 87.2%,the specifi city was 43.4%,and the diagnostic cutoff was 167°(P<0.001).The AUC of lipid plaque length predicting layered plaque was 0.688,the sensitivity was 77.1%,the specifi city was 54.0%,and the diagnostic cut-off was 11.8mm(P<0.001).There was signifi cant diff erence in 9-month cumulative mace between non layered plaque and layered plaque patients(P=0.038).There were more major cardiovascular events in layered plaque group.Conclusions Layered plaque not only reflects the past healing history of plaque rupture or thrombosis,it also refl ects the vulnerability of lipid plaques,which may be valuable in predicting the potential risk of future coronary artery events.