J Korean Med Sci.  2012 Apr;27(4):370-376. 10.3346/jkms.2012.27.4.370.

Relation between Anemia and Vulnerable Coronary Plaque Components in Patients with Acute Coronary Syndrome: Virtual Histology-Intravascular Ultrasound Analysis

• Hong YJ
• Jeong MH
• Choi YH
• Song JA
• Kim DH
• Lee KH
• Yamanaka F
• Lee MG
• Park KH
• Sim DS
• Yoon NS
• Yoon HJ
• Kim KH
• Park HW
• Kim JH
• Ahn Y
• Cho JG
• Park JC
• Kang JC

• KMID: 2157896
• DOI: http://doi.org/10.3346/jkms.2012.27.4.370

Abstract

The aim of the present study was to evaluate the plaque components and the predictors of thin-cap fibroatheroma (TCFA) in anemic patients with acute coronary syndrome using virtual histology-intravascular ultrasound (VH-IVUS). Anemia was defined according to criteria of the World Health Organization, (i.e. , hemoglobin levels < 13 g/dL in men and < 12 g/dL in women) and we compared VH-IVUS findings between anemia group (171 patients, 260 lesions) and non-anemia group (569 patients, 881 lesions). Anemia group had greater % necrotic core (NC) volume (21% +/- 9% vs 19% +/- 9%, P = 0.001) compared with non-anemia group. Hemoglobin level correlated negatively with absolute NC volume (r = -0.235, P < 0.001) and %NC volume (r = -0.209, P < 0.001). Independent predictors of TCFA by multivariate analysis were diabetes mellitus (odds ratio [OR], 2.213; 95% confidence interval [CI], 1.403-3.612, P = 0.006), high-sensitivity C-reactive protein (OR, 1.143; 95% CI, 1.058-1.304, P = 0.012), microalbuminuria (albumin levels of 30 to 300 mg/g of creatinine) (OR, 2.124; 95% CI, 1.041-3.214, P = 0.018), and anemia (OR: 2.112; 95% CI 1.022-3.208, P = 0.028). VH-IVUS analysis demonstrates that anemia at the time of clinical presentation is associated with vulnerable plaque component in patients with acute coronary syndrome.

Keyword

Acute Coronary Syndrome; Plaque; Anemia; Intravascular Ultrasound

MeSH Terms

Acute Coronary Syndrome/complications/*pathology/ultrasonography
Aged
Albuminuria/urine
Anemia/complications/*diagnosis
C-Reactive Protein/analysis
Coronary Angiography
Creatinine/blood
Diabetes Complications
Female
Hemoglobins/analysis
Humans
Male
Middle Aged
Necrosis/pathology
Odds Ratio
Plaque, Atherosclerotic/*ultrasonography
Predictive Value of Tests
*Ultrasonography, Interventional

Figure

• 

  Fig. 1 Plaque component analysis according to the presence or absence of anemia at the minimum lumen sites. Results are displayed for (A) absolute and (B) relative quantifications. FT, fibrotic; FF, fibro-fatty; DC, dense calcium; NC, necrotic core.

• 

  Fig. 2 Plaque component analysis according to the presence or absence of anemia at the largest necrotic core sites. Results are displayed for (A) absolute and (B) relative quantifications. FT, fibrotic; FF, fibro-fatty; DC, dense calcium; NC, necrotic core.

• 

  Fig. 3 Volumetric plaque component analysis according to the presence or absence of anemia. Results are displayed for (A) absolute and (B) relative quantifications. FT, fibrotic; FF, fibro-fatty; DC, dense calcium; NC, necrotic core.

Reference

1. Sarnak MJ, Tighiouart H, Manjunath G, MacLeod B, Griffith J, Salem D, Levey AS. Anemia as a risk factor for cardiovascular disease in The Atherosclerosis Risk in Communities (ARIC) study. J Am Coll Cardiol. 2002. 40:27–33.

2. Sabatine MS, Morrow DA, Giugliano RP, Burton PB, Murphy SA, McCabe CH, Gibson CM, Braunwald E. Association of hemoglobin levels with clinical outcomes in acute coronary syndromes. Circulation. 2005. 111:2042–2049.

3. Nikolsky E, Aymong ED, Halkin A, Grines CL, Cox DA, Garcia E, Mehran R, Tcheng JE, Griffin JJ, Guagliumi G, Stuckey T, Turco M, Cohen DA, Negoita M, Lansky AJ, Stone GW. Impact of anemia in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention: analysis from the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) Trial. J Am Coll Cardiol. 2004. 44:547–553.

4. Archbold RA, Balami D, Al-Hajiri A, Suliman A, Liew R, Cooper J, Ranjadayalan K, Knight CJ, Deaner A, Timmis AD. Hemoglobin concentration is an independent determinant of heart failure in acute coronary syndromes: cohort analysis of 2310 patients. Am Heart J. 2006. 152:1091–1095.

5. Ezekowitz JA, McAlister FA, Armstrong PW. Anemia is common in heart failure and is associated with poor outcomes: insights from a cohort of 12065 patients with new-onset heart failure. Circulation. 2003. 107:223–225.

6. McKechnie RS, Smith D, Montoye C, Kline-Rogers E, O'Donnell MJ, DeFranco AC, Meengs WL, McNamara R, McGinnity JG, Patel K, Share D, Riba A, Khanal S, Moscucci M. Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). Prognostic implication of anemia on in-hospital outcomes after percutaneous coronary intervention. Circulation. 2004. 110:271–277.

7. Lee PC, Kini AS, Ahsan C, Fisher E, Sharma SK. Anemia is an independent predictor of mortality after percutaneous coronary intervention. J Am Coll Cardiol. 2004. 44:541–546.

8. DeFoe GR, Ross CS, Olmstead EM, Surgenor SD, Fillinger MP, Groom RC, Forest RJ, Pieroni JW, Warren CS, Bogosian ME, Krumholz CF, Clark C, Clough RA, Weldner PW, Lahey SJ, Leavitt BJ, Marrin CA, Charlesworth DC, Marshall P, O'Connor GT. Northern New England Cardiovascular Disease Study Group. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Ann Thorac Surg. 2001. 71:769–776.

9. Nutritional Anaemias. Report of a WHO Scientific Group. World Health Organization Technical Report Series No. 405. 1968. Geneva: World Health Organisation;9–10.

10. Roberts WL, Moulton L, Law TC, Farrow G, Cooper-Anderson M, Savory J, Rifai N. Evaluation of nine automated high-sensitivity C-reactive protein methods: implications for clinical and epidemiological applications. Part 2. Clin Chem. 2001. 47:418–425.

11. Eknoyan G, Hostetter T, Bakris GL, Hebert L, Levey AS, Parving HH, Steffes MW, Toto R. Proteinuria and other markers of chronic kidney disease: a position statement of the National Kidney Foundation (NKF) and the National Institute of Diabetes and Digestive and Kidney diseases (NIDDK). Am J Kidney Dis. 2003. 42:617–622.

12. TIMI IIIB Investigators. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIB Trial. Thrombolysis in Myocardial Ischemia. Circulation. 1994. 89:1545–1556.

13. Mintz GS, Nissen SE, Anderson WD, Bailey SR, Erbel R, Fitzgerald PJ, Pinto FJ, Rosenfield K, Siegel RJ, Tuzcu EM, Yock PG. American College of Cardiology clinical expert consensus document on standards for acquisition, measurement and reporting of intravascular ultrasound studies (IVUS): a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2001. 37:1478–1492.

14. Nair A, Kuban BD, Tuzcu EM, Schoenhagen P, Nissen SE, Vince DG. Coronary plaque classification with intravascular ultrasound radiofrequency data analysis. Circulation. 2002. 106:2200–2206.

15. Rodriguez-Granillo GA, García-García HM, Mc Fadden EP, Valgimigli M, Aoki J, de Feyter P, Serruys PW. In vivo intravascular ultrasound-derived thin-cap fibroatheroma detection using ultrasound radiofrequency data analysis. J Am Coll Cardiol. 2005. 46:2038–2042.

16. Okubo M, Kawasaki M, Ishihara Y, Takeyama U, Yasuda S, Kubota T, Tanaka S, Yamaki T, Ojio S, Nishigaki K, Takemura G, Saio M, Takami T, Fujiwara H, Minatoguchi S. Tissue characterization of coronary plaques: comparison of integrated backscatter intravascular ultrasound with virtual histology intravascular ultrasound. Circ J. 2008. 72:1631–1639.

17. Yamamoto M, Takano M, Okamatsu K, Murakami D, Inami S, Xie Y, Seimiya K, Ohba T, Seino Y, Mizuno K. Relationship between thin cap fibroatheroma identified by virtual histology and angioscopic yellow plaque in quantitative analysis with colorimetry. Circ J. 2009. 73:497–502.

18. Davies MJ, Thomas A. Thrombosis and acute coronary-artery lesions in sudden cardiac ischemic death. N Engl J Med. 1984. 310:1137–1140.

19. Farb A, Burke AP, Tang AL, Liang TY, Mannan P, Smialek J, Virmani R. Coronary plaque erosion without rupture into a lipid core. A frequent cause of coronary thrombosis in sudden coronary death. Circulation. 1996. 93:1354–1363.

20. Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. Lessons from sudden coronary death: a comprehensive morphological classification scheme for atherosclerotic lesions. Arterioscler Thromb Vasc Biol. 2000. 20:1262–1275.

21. Falk E, Shah PK, Fuster V. Coronary plaque disruption. Circulation. 1995. 92:657–671.

22. Silva JA, Escobar A, Collins TJ, Ramee SR, White CJ. Unstable angina: a comparison of angioscopic findings between diabetic and nondiabetic patients. Circulation. 1995. 92:1731–1736.

23. Hong MK, Mintz GS, Lee CW, Suh J, Kim JH, Park DW, Lee SW, Kim YH, Cheong SS, Kim JJ, Park SW, Park SJ. Comparison of virtual histology to intravascular ultrasound of culprit coronary lesions in acute coronary syndrome and target coronary lesions in stable angina pectoris. Am J Cardiol. 2007. 100:953–959.

24. Libby P. Molecular bases of the acute coronary syndromes. Circulation. 1995. 91:2844–2850.

25. Davies MJ, Richardson PD, Woolf N, Katz DR, Mann J. Risk of thrombosis in human atherosclerotic plaques: role of extracellular lipid, macrophage, and smooth muscle cell content. Br Heart J. 1993. 69:377–381.

26. Buja LM, Willerson JT. Role of inflammation in coronary plaque disruption. Circulation. 1994. 89:503–505.

27. Moscucci M, Fox KA, Cannon CP, Klein W, López-Sendón J, Montalescot G, White K, Goldberg RJ. Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE). Eur Heart J. 2003. 24:1815–1823.

28. Rao SV. Implications of bleeding and blood transfusion in percutaneous coronary intervention. Rev Cardiovasc Med. 2007. 8:S18–S26.

29. Bassand JP. Impact of anaemia, bleeding and transfusions in acute coronary syndromes: a shift in the paradigm. Eur Heart J. 2007. 28:1273–1274.

30. Go AS, Yang J, Ackerson LM, Lepper K, Robbins S, Massie BM, Shlipak MG. Hemoglobin level, chronic kidney disease, and the risks of death and hospitalization in adults with chronic heart failure: the Anemia in Chronic Heart Failure: Outcomes and Resource Utilization (ANCHOR) study. Circulation. 2006. 113:2713–2723.