The relationship between Hemoglobin A1c and the maximal plaque stress of culprit ruptured plaques in patients with ST-segment elevated myocardial infarction

https://doi.org/10.1016/j.ijcard.2022.04.072Get rights and content

Highlights

  • The first study to assess relationship of maximal plaque stress and cardiovascular risk factors in patients with plaque rupture based on optical coherence tomography.

  • Patients with higher level of HAb1c exhibits higher maximal plaque stress.

  • Maximal plaque stress is determined by fibrous cap thickness and maximal lipid arc.

Abstract

Background

Plaque rupture occurs when the structural stress inside plaques exceeds the capacity of the overlying fibrous cap. Plaque structural stress has been acknowledged as an index to evaluate the risk of plaque rupture. However, impacting factors associated with the level of plaque structural stress in ST-segment elevated myocardial infarction patients with ruptured plaques remain unknown.

Methods

Based on optical coherence tomography, we analyzed the plaque characteristics and calculated the maximal plaque stress of the culprit lesions in 162 patients with plaque rupture by performing finite element analysis. All enrolled patients were divided into two groups according to the level of maximal plaque stress. Cardiovascular risk factors, laboratory findings and clinical outcomes were compared between the two groups.

Results

Hemoglobin A1c (HbA1c) was significantly higher in the high stress group than in the low stress group (7.0% ± 1.8 vs. 6.3% ± 1.2, p = 0.003). The maximal plaque stress of patients with diabetes was significantly higher than that of patients without diabetes (538.7 kPa [346.2–810.6] vs. 425.9 kPa [306.2–571.4], p = 0.006). Moreover, the level of maximal plaque stress was significantly associated with HbA1c (Pearson's correlation coefficient: r = 0.289, P < 0.001). OCT findings showed that the fibrous cap thickness and maximal lipid arc were significantly associated with maximal plaque stress (r = −0.163, p = 0.038; r = 0.194, p = 0.013, respectively).

Conclusion

OCT-based finite-element analysis showed that HbA1c was independently associated with the level of maximal plaque stress in STEMI patients with plaque rupture, thus indicating the importance of glucose control in patients with coronary atherosclerotic disease.

Introduction

Acute myocardial infarction (AMI) has a high mortality, and it is the leading cause of death in humans [1]. Compared with plaque erosion or calcified nodules, plaque rupture (PR) is the most common and severe phenotype of AMI, and it usually has a poor prognosis [2]. In addition to inflammation and the vulnerable features of plaques, increased plaque structure stress is considered a potential trigger of PR [3,4]. The structure stress is influenced by plaque morphology, composition and boundary load, and it can be computed based on modalities of intravascular images [[5], [6], [7]]. Morpho mechanical finite element analysis (FEA) is a classical method that is used to calculate the tensile stress of coronary lesions by separating different tissues according to their mechanical properties and discretizing them into meshes. Optical coherence tomography (OCT) is an intravascular imaging technique with very high resolution that shows different periluminal structures in vivo [8]. It has high potential for use in FEA. In a recent study, Milzi et al. built a plaque model based on OCT images for FEA to determine plaque stress and predict plaque rupture with high sensitivity and specificity compared with classical features of plaque vulnerability [9].

However, the recent study with a small sample size merely focused on plaque structure stress between ruptured and nonruptured plaques [6,9]. Interestingly, we also found that the maximal plaque stress among patients with PR showed a large span from 100 to 600 kPa [9] but the analysis about this diversity is lacking. Therefore, herein we sought to explore the differences in stress in ruptured plaques and identify risk factors that account for high plaque stress in patients with ST-segment elevation myocardial infarction (STEMI).

Section snippets

Study population

From March 2017 to January 2020, 576 patients with STEMI who underwent OCT imaging of culprit lesions in Fuwai Hospital were consecutively recruited (Fuwai Hospital OCTAMI Registry, clinical trials.gov: NCT03593928). After excluding patients without preintervention OCT images (n = 14), patients with poor OCT image quality (n = 93), patients with in-stent restenosis (n = 48) and patients with other plaque phenotypes (n = 224), the remaining 162 patients with plaque rupture and clear structural

Baseline characteristics

A total of 162 STEMI patients with PR were enrolled in this study. According to the level of maximal plaque stress, we divided the cohort into a high stress group (n = 81) and a low stress group (n = 81). The baseline characteristics, including age, sex, risk factors, laboratory parameters and OCT findings, are listed in Table 1. Age and sex were similar, and no significant difference in cardiovascular risk factors was observed between the two groups. Laboratory findings showed that HbA1c in

Discussion

To the best of our knowledge, this is the first study to demonstrate the variety of maximal plaque stresses in STEMI patients with PR. The current study mainly concentrated on the influencing factors that are related to levels of maximal plaque stress in PR patients. Herein, we excluded patients with plaque erosion, calcified nodules and other phenotypes whose pathological mechanisms were less affected by plaque stress. Based on OCT images and finite element analysis, we found that maximal

Limitations

First, OCT is limited to observing the deep vessel wall, so some structure in the media layer may be lost. This can be assessed and supplemented by other image modalities, such as IVUS or coronary computed tomography, in future studies. Second, this was a single-center study with a small sample size, and a validation cohort was lacking. Third, we excluded other pathological plaque phenotypes, including plaque erosion and calcified nodules; therefore, selection bias may exist. Fourth, some

Conclusion

There is a large diversity of plaque structural stress in STEMI patients with PR. Among them, patients with diabetes had significantly higher maximal plaque stress than those without diabetes. In addition, our study found an independent association between HbA1c levels and maximal plaque stress based on OCT images in STEMI patients with plaque rupture.

Financial support

This study was supported by the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (2016-I2M-1–009), National Natural Science Funds (number: 81970308), the Fund of “Sanming” Project of Medicine in Shenzhen (number: SZSM201911017) and Shenzhen Key Medical Discipline Construction Fund (number: SZXK001).

The following are the supplementary data related to this article.

Author contributions

Jiannan Li: substantial contribution to the conception and design of research, data acquisition, statistical analysis and manuscript drafting. Runzhen Chen and Jinying Zhou: substantial contribution to the conception and design of research, data acquisition. Ying Wang, Xiaoxiao Zhao and Shaodi Yan: substantial contribution to data acquisition. Chen Liu, Peng Zhou, Li Song, Hanjun Zhao: substantial contribution to patients' enrollment and cardiac intervention. Hongbing Yan: substantial

Ethics approval and consent to participate

It is from the ethics committee of the department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, China.

Consent for publication

Written informed consent for publication was obtained from all participants.

Availability of data and materials

The datasets used and/or analyzed during this study are available from the corresponding author on reasonable request.

Declaration of Competing Interest

1. Non-financial competing interests. 2. Non-financial competing interests include family associations, political, religious, academic or any other.

Acknowledgements

The authors gratefully acknowledge all individuals who participated in this study.

References (40)

  • C.R. Kelly et al.

    Relation of C-reactive protein levels to instability of untreated vulnerable coronary plaques (from the Prospect Study) [J]

    Am. J. Cardiol.

    (2014)
  • C. Costopoulos et al.

    Heterogeneity of plaque structural stress is increased in plaques leading to mace: insights from the prospect study [J]

    JACC Cardiovasc. Imaging

    (2020)
  • R. Vedanthan et al.

    Global perspective on acute coronary syndrome: a burden on the young and poor [J]

    Circ. Res.

    (2014)
  • G. Niccoli et al.

    Plaque rupture and intact fibrous cap assessed by optical coherence tomography portend different outcomes in patients with acute coronary syndrome [J]

    Eur. Heart J.

    (2015)
  • D. Tang et al.

    Sites of rupture in human atherosclerotic carotid plaques are associated with high structural stresses: an in vivo Mri-based 3D fluid-structure interaction study [J]

    Stroke

    (2009)
  • G.C. Cheng et al.

    Distribution of circumferential stress in ruptured and stable atherosclerotic lesions. A structural analysis with histopathological correlation [J]

    Circulation

    (1993)
  • I.K. Jang et al.

    In vivo characterization of coronary atherosclerotic plaque by use of optical coherence tomography [J]

    Circulation

    (2005)
  • A. Milzi et al.

    Coronary plaque composition influences biomechanical stress and predicts plaque rupture in a morpho-mechanic Oct analysis [J]

    Elife

    (2021)
  • H.M. Loree et al.

    Effects of fibrous cap thickness on peak circumferential stress in model atherosclerotic vessels [J]

    Circ. Res.

    (1992)
  • G. Finet et al.

    Biomechanical interaction between cap thickness, lipid core composition and blood pressure in vulnerable coronary plaque: impact on stability or instability [J]

    Coron. Artery Dis.

    (2004)
  • Cited by (0)

    View full text