Atherosclerotic cardiovascular disease results in >19 million deaths annually, and coronary heart disease accounts for the majority of this toll. Despite major advances in treatment of coronary heart disease patients, a large number of victims of the disease who are apparently healthy die suddenly without prior symptoms. Available screening and diagnostic methods are insufficient to identify the victims before the event occurs. The recognition of the role of the vulnerable plaque has opened new avenues of opportunity in the field of cardiovascular medicine. This consensus document concludes the following. (1) Rupture-prone plaques are not the only vulnerable plaques. All types of atherosclerotic plaques with high likelihood of thrombotic complications and rapid progression should be considered as vulnerable plaques. We propose a classification for clinical as well as pathological evaluation of vulnerable plaques. (2) Vulnerable plaques are not the only culprit factors for the development of acute coronary syndromes, myocardial infarction, and sudden cardiac death. Vulnerable blood (prone to thrombosis) and vulnerable myocardium (prone to fatal arrhythmia) play an important role in the outcome. Therefore, the term "vulnerable patient" may be more appropriate and is proposed now for the identification of subjects with high likelihood of developing cardiac events in the near future. (3) A quantitative method for cumulative risk assessment of vulnerable patients needs to be developed that may include variables based on plaque, blood, and myocardial vulnerability. In Part I of this consensus document, we cover the new definition of vulnerable plaque and its relationship with vulnerable patients. Part II of this consensus document focuses on vulnerable blood and vulnerable myocardium and provide an outline of overall risk assessment of vulnerable patients. Parts I and II are meant to provide a general consensus and overviews the new field of vulnerable patient. Recently developed assays (eg, C-reactive protein), imaging techniques (eg, CT and MRI), noninvasive electrophysiological tests (for vulnerable myocardium), and emerging catheters (to localize and characterize vulnerable plaque) in combination with future genomic and proteomic techniques will guide us in the search for vulnerable patients. It will also lead to the development and deployment of new therapies and ultimately to reduce the incidence of acute coronary syndromes and sudden cardiac death. We encourage healthcare policy makers to promote translational research for screening and treatment of vulnerable patients.

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From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part II.

During the past decade, our understanding of the pathophysiology of coronary artery disease (CAD) has undergone a remarkable evolution. We review here how these advances have altered our concepts of and clinical approaches to both the chronic and acute phases of CAD. Previously considered a cholesterol storage disease, we currently view atherosclerosis as an inflammatory disorder. The appreciation of arterial remodeling (compensatory enlargement) has expanded attention beyond stenoses evident by angiography to encompass the biology of nonstenotic plaques. Revascularization effectively relieves ischemia, but we now recognize the need to attend to nonobstructive lesions as well. Aggressive management of modifiable risk factors reduces cardiovascular events and should accompany appropriate revascularization. We now recognize that disruption of plaques that may not produce critical stenoses causes many acute coronary syndromes (ACS). The disrupted plaque represents a "solid-state" stimulus to thrombosis. Alterations in circulating prothrombotic or antifibrinolytic mediators in the "fluid phase" of the blood can also predispose toward ACS. Recent results have established the multiplicity of "high-risk" plaques and the widespread nature of inflammation in patients prone to develop ACS. These findings challenge our traditional view of coronary atherosclerosis as a segmental or localized disease. Thus, treatment of ACS should involve 2 overlapping phases: first, addressing the culprit lesion, and second, aiming at rapid "stabilization" of other plaques that may produce recurrent events. The concept of "interventional cardiology" must expand beyond mechanical revascularization to embrace preventive interventions that forestall future events.

Pathophysiology of Coronary Artery Disease

Inflammation and cardiovascular disease mechanisms

American association of clinical endocrinologists and american college of endocrinology guidelines for management of dyslipidemia and prevention of cardiovascular disease

Traditional risk factors like hypercholesterolemia are important for atherogenesis, but it is now apparent that the immune system also plays an important role. Uncovering the mechanisms by which specific components of the immune system impact atherogenesis will not only provide new insights into the pathogenesis of lesion formation, but could also lead to novel therapeutic approaches that involve immune modulation.

Innate and acquired immunity in atherogenesis.

Background—Most of our knowledge about atherosclerosis at young ages is derived from necropsy studies, which have inherent limitations. Detailed, in vivo data on atherosclerosis in young individuals are limited. Intravascular ultrasonography provides a unique opportunity for in vivo characterization of early atherosclerosis in a clinically relevant context. Methods and Results—Intravascular ultrasound was performed in 262 heart transplant recipients 30.9±13.2 days after transplantation to investigate coronary arteries in young asymptomatic subjects. The donor population consisted of 146 men and 116 women (mean age of 33.4±13.2 years). Extensive imaging of all possible (including distal) coronary segments was performed. Sites with the greatest and least intimal thickness in each CASS segment were measured in multiple coronary arteries. Sites with intimal thickness ≥0.5 mm were defined as atherosclerotic. A total of 2014 sites within 1477 segments in 574 coronary arteries (2.2 arteries per person) were anal...

High Prevalence of Coronary Atherosclerosis in Asymptomatic Teenagers and Young Adults Evidence From Intravascular Ultrasound

Electrophysiological characteristics of epicardial atrial tachycardias and endocardial breakthrough site targeting for ablation: a single center experience.

A 63-year-old man with active COVID-19 infection and a history of coronary artery bypass grafting presented with acute thrombotic occlusion of saphenous venous graft which was anastomosed to the left anterior descending artery. Initial antegrade approach, complicated by a small leakage in the distal left anterior descending artery, was later converted to a retrograde approach via occluded saphenous vein graft. After successful stenting, TIMI 3 flow was achieved.

Thrombotic Complication of COVID-19: A Case Report of Acute Saphenous Vein Graft Thrombosis in a Newly Diagnosed Patient.

Background: Cardioneuroablation is one of the emerging therapies in vasovagal syncope. In this study, we present a simple method of cardioneuroablation performed via a right-sided approach, targeting anterior-right and right-inferior ganglionated plexi, along with procedural and follow-up data. Methods: Patients who had underwent cardioneuroablation between March 2018 and September 2019 with vasovagal syncope in 2 clinics were enrolled in the study. All patients underwent radio-anatomically guided radiofrequency ablation targeting anterior-right ganglionated plexi and right-inferior ganglionated plexi. Syncope and symptom burden, 24-hour ambulatory electrocardiogram data at presentation, and at follow-up were assessed along with procedural data. Results: A total of 23 patients underwent modified right-sided cardioneuroablation. Mean basal cycle length decreased significantly from 862.3 ± 174.5 ms at the beginning of the procedure 695.8 ± 152.1 ms following the final radiofrequency ablation (P < .001). Mean 24-hour ambulatory heart rate increased significantly from 66.4 ± 10.7 bpm at baseline to 80 ± 7.6 bpm at follow-up (P < .001). Only 1 patient had 1 episode of syncope following the procedure at the mean follow-up period of 10 ± 2.9 months. The same patient had recurrent presyncope. Conclusion: The right-sided cardioneuroablation approach was found to be an effective treatment for vasovagal syncope and may be regarded as a default initial cardioneuroablation technique.

https://doi.org/10.5152/anatoljcardiol.2022.217

Procedural Characteristics, Safety, and Follow-up of Modified Right-Sided Approach for Cardioneuroablation

Akut koroner total oklüzyon kestiriminde yeni gelişimli atriyoventriküler blok varlığının rolü: nadir bir STYzME olgusu

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Eralp Tutar

Papers

High Prevalence of Coronary Atherosclerosis in Asymptomatic Teenagers and Young Adults Evidence From Intravascular Ultrasound

Electrophysiological characteristics of epicardial atrial tachycardias and endocardial breakthrough site targeting for ablation: a single center experience.

Thrombotic Complication of COVID-19: A Case Report of Acute Saphenous Vein Graft Thrombosis in a Newly Diagnosed Patient.

Procedural Characteristics, Safety, and Follow-up of Modified Right-Sided Approach for Cardioneuroablation

Role of new-onset atrioventricular block in prediction of acute coronary total occlusion: a rare case of NSTEMI