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Determinants of ST-segment elevation myocardial infarction as clinical presentation of acute coronary syndrome

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Abstract

Antiplatelet agents and statin therapies are widely used in patients with known cardiovascular disease. Plaque rupture (PR) and plaque erosion (PE) are the most frequent underlying mechanisms of acute coronary syndromes (ACS). The conditions and medications that are associated with ST-segment elevation myocardial infarction (STEMI) following PR or PE have not been systematically studied. A total of 838 ACS patients (494 with STEMI, 344 with NSTE-ACS) who were diagnosed with PR or PE by optical coherence tomography were included. The patients were categorized into two groups based on underlying pathology, and the baseline characteristics and culprit plaque morphology associated with STEMI were investigated within each group. Among 838 patients, 467 (55.7%) had PR, and 371 (44.3%) were diagnosed with PE. Among patients with PR, older age, hyperlipidemia, no antiplatelet therapy, higher level of low-density lipoprotein cholesterol, and greater lipid burden and macrophage infiltration were associated with increased probability of STEMI. Among patients with PE, no dual antiplatelet therapy and no statin therapy were associated with increased probability of STEMI. The incidence of STEMI caused by PR was significantly lower on antiplatelet therapy (P < 0.001), and the incidence of STEMI caused by PE was significantly lower on antiplatelet therapy (P < 0.001) or on statin therapy (P < 0.001). Antiplatelet therapy is associated with lower probability of STEMI, regardless of underlying pathology, and statin therapy is associated with lower probability of STEMI in PE as clinical presentation of ACS.

Graphic Abstract

Statin therapy prior to the onset of acute coronary syndromes (ACS) may reduce the probability of plaque rupture. Antiplatelet therapy prior to the onset of ACS is associated with reduced probability of ST-segment elevation myocardial infarction (STEMI) following both plaque rupture and plaque erosion, and dual antiplatelet therapy offers additional protection compared to a single antiplatelet agent in plaque erosion. The combination of statin and antiplatelet therapy may have an additive effect on reducing the probability of STEMI caused by plaque erosion.

Yellow: lipid pool(necrotic core); red: fibrin-rich thrombus; gray; platelet-rich thrombus

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Acknowledgements

Dr. Jang’s research was supported by Mr. and Mrs. Allan and Gill Gray and by Mr. and Mrs. Michael and Kathryn Park.

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Authors and Affiliations

  1. Cardiology Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRB 800, Boston, MA, 02114, USA

    Osamu Kurihara, Erika Yamamoto, Hyung Oh Kim, Michele Russo, Iris McNulty, Makoto Araki, Akihiro Nakajima & Ik -Kyung Jang

  2. Cardiovascular Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamakari, Inzai, Chiba, 270-1694, Japan

    Masamichi Takano

  3. Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan

    Tsunekazu Kakuta

  4. Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan

    Tsunenari Soeda

  5. Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy

    Filippo Crea

  6. Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium

    Tom Adriaenssens

  7. Department of Cardiology, University of Giessen, Giessen, Germany

    Holger M. Nef & Niklas F. Boeder

  8. Biostatistics Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA

    Hang Lee

  9. Mitsukoshi Health and Welfare Foundation, Tokyo, Japan

    Kyoichi Mizuno

  10. Department of Cardiology, Kyung Hee University Hospital, Seoul, Korea

    Ik -Kyung Jang

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  1. Osamu Kurihara
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  2. Masamichi Takano
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Correspondence to Masamichi Takano or Ik -Kyung Jang.

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Conflict of interest

Dr. Jang has received educational grants from Abbott Vascular and a consulting fee from Svelte Medical Systems. They had no role in the design or conduct of this research. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Kurihara, O., Takano, M., Kakuta, T. et al. Determinants of ST-segment elevation myocardial infarction as clinical presentation of acute coronary syndrome. J Thromb Thrombolysis 51, 1026–1035 (2021). https://doi.org/10.1007/s11239-020-02281-7

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