The Vulnerable Plaque

Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671.

Large Lipid Core

Thin, Vulnerable, Fibrous Cap

Ruptured Plaque with Occlusive Thrombus Formation

Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671.

ThrombusFormation

Atherothrombosis: Thrombus Superimposed on Atherosclerotic Plaque

Adapted with permission from Falk E, et al. Circulation. 1998;92:657-671. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Characteristics of Unstable and Stable Plaque

Thin fibrous cap

Inflammatory cells

FewSMCs

Erodedendothelium

Activatedmacrophages

Thickfibrous cap

Lack ofinflammatory cells

Foam cells

Intactendothelium

MoreSMCs

Adapted with permission from Libby P. Circulation. 1995;91:2844-2850. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Unstable Stable

Thrombus Formation and ACS

UA NQMI STE-MI

Plaque Disruption/Fissure/Erosion

Thrombus Formation

Non-ST-Segment Elevation Acute Coronary Syndrome (ACS)

ST-Segment Elevation Acute Coronary Syndrome (ACS)

Old Terminology:

NewTerminology:

Superficial Erosion

Modified from Libby PCirc 104:365,2001

Ruptured Fibrous Cap

Sudden Thrombus or Thromboembolism

PathophysiologyAngiographic evidence of coronary thrombus formation may be seen in:>90% of patients with STEMI 35-75% of patients with unstable angina or NSTEMI1% of patients with stable angina

No ST Elevation ST Elevation

Acute Coronary Syndrome

NQMI Qw MI

NSTEMI

Myocardial Infarction

Davies MJ Heart 83:361, 2000

Ischemic DiscomfortPresentation

Working Dx

ECG

Biochem. Marker

Hamm Lancet 358:1533,2001

Unstable AnginaFinal Dx

Clinical presentation

• Chronic stable angina or chronic stable angina(CCS)

• Acute coronary syndrome(ACS)

Abbreviations

•Precipitating Factor •Quality•Relief•Site •Time

VERY VERY IMPORTANT

• Effect of CAD RF like DM, HTN, HLP on history taking in Unstable angina

• History taking is very very important so …….