Percutaneous Coronary Angioscopy: Its Contribution to the Pathophysiological Interpretation of the Acute Ischemic Syndromes

pp 121-131

Abstract

Background

Though plaque rupture and thrombosis are considered the main pathophysiological mechanisms of unstable angina and acute myocardial infarction, there are others that can also be involved. Coronary angioscopy is the only percutaneous method that allows to directly visualize such accidents. We have defined angioscopy standards of diverse complexity, analyzing: color, intimal continuity and surface of the atheromatosus plaque: A: normal artery; B: atheroma without complexity; C: complex atheroma; D: atheroma complicated with red thrombus.

Methods

With the aim of determining through percutaneous coronary angioscopy the prevalence of plaque rupture and thrombus in unstable angina and Q-wave acute myocardial infarction, and to correlate the angioscopic discovery with the modalities of clinic presentation of the unstable angina, we study 23 patients with percutaneous coronary angioscopy prospectively (18 men, 5 women, of 58 ±9.5 years),19 of them with unstable angina and 4 with Q-wave acute myocardial infarction.We have excluded of this analysis two patients with restenosis (unpigmented fibrotic standard) and one with insufficient angioscopy diagnosis. The patients with unstable angina are distributed in 3 groups, following the Braunwald simplified classification: UA-I: serious angina of new onset or accelerated angina; no rest pain (5 patients). UA-II: rest angina in the last month but not within 48 hours (5 patients), and UA-III: rest angina within 48 hours (6 patients, 3 of them refractary to the medical treatment).

Results

In the four patients with Q-wave acute myocardial infarction the angiocopy standards found was typeD (red thrombus 4/4; mural 1/4, occlusive 3/4). In the unstable angina patients the following angioscopy standards were observed:

                                         A            B           C/D

UA-I                                 0              5             0

UA-II                                0              4             1

UA-III*                             0              1             5

_{* Angioscopy standards in UA-III versus UA-I/II: p < 0.025.Ten patients with UA-I/II treated with angioplasty and/or atherectomy improved without complications; 2/6 with UA-III treated on the same way, suffered acute and.subacute coronary occlusion respectively.}

Conclusions

1) Q-wave acute myocardial infarction is caracterized by an angioscopy standards of plaque complicated with thrombus. 2) The clinical risk in unstable angina correlates with the magnitude and degree of complication in the plaque studied angioscopically.