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

Area of Science:

• Cardiovascular Medicine
• Pathology
• Biomarkers

Background:

• Atherosclerotic cardiovascular disease causes millions of deaths annually, with coronary heart disease being a major contributor.
• Sudden cardiac death in apparently healthy individuals highlights limitations in current screening methods for coronary heart disease.
• The concept of vulnerable plaque has emerged as a critical area for understanding and preventing acute cardiac events.

Purpose of the Study:

• To redefine vulnerable plaques beyond rupture-prone types to include those with thrombotic complications and rapid progression.
• To introduce the concept of the "vulnerable patient" encompassing plaque, blood, and myocardial factors for comprehensive risk assessment.
• To outline a framework for evaluating and managing patients at high risk of acute coronary syndromes and sudden cardiac death.

Main Methods:

• Consensus document development involving clinical and pathological evaluation criteria for vulnerable plaques.
• Integration of plaque characteristics, blood thrombogenicity, and myocardial electrical stability into a "vulnerable patient" definition.
• Review of existing and emerging diagnostic tools including biomarkers (e.g., C-reactive protein), imaging (CT, MRI), electrophysiological tests, and catheter-based techniques.

Main Results:

• Vulnerable plaques are defined broadly to include all atherosclerotic plaques with a high likelihood of thrombotic complications or rapid progression.
• The "vulnerable patient" concept is proposed, integrating vulnerable plaque, vulnerable blood (thrombosis-prone), and vulnerable myocardium (arrhythmia-prone).
• A need for quantitative risk assessment methods incorporating these multi-faceted vulnerability criteria is identified.

Conclusions:

• The definition of vulnerable plaque has been expanded to encompass a wider range of high-risk lesions.
• The "vulnerable patient" paradigm offers a more holistic approach to identifying individuals at imminent risk of cardiac events.
• Advancements in diagnostics and future research in genomics and proteomics are crucial for screening, treatment, and reducing the incidence of sudden cardiac death and acute coronary syndromes.