Culprit plaque morphology determines inflammatory risk and clinical outcomes in acute coronary syndrome

AIMS

Rupture of the fibrous cap (RFC) and erosion of an intact fibrous cap (IFC) are the two predominant mechanisms causing acute coronary syndromes (ACS). It is uncertain whether clinical outcomes are different following RFC-ACS vs. IFC-ACS and whether this is affected by a specific inflammatory response. The prospective, translational OPTIcal-COherence Tomography in Acute Coronary Syndrome study programme investigates the impact of the culprit lesion phenotype on inflammatory profiles and prognosis in ACS patients.

METHODS AND RESULTS

This analysis included 398 consecutive ACS patients, of which 62% had RFC-ACS and 25% had IFC-ACS. The primary endpoint was a composite of cardiac death, recurrent ACS, hospitalization for unstable angina, and target vessel revascularization at 2 years [major adverse cardiovascular events (MACE+)]. Inflammatory profiling was performed at baseline and after 90 days. Patients with IFC-ACS had lower rates of MACE+ than those with RFC-ACS (14.3% vs. 26.7%, P = 0.02). In 368-plex proteomic analyses, patients with IFC-ACS showed lower inflammatory proteome expression compared with those with RFC-ACS, including interleukin-6 and proteins associated with the response to interleukin-1β. Circulating plasma levels of interleukin-1β decreased from baseline to 3 months following IFC-ACS (P < 0.001) but remained stable following RFC-ACS (P = 0.25). Interleukin-6 levels decreased in patients with RFC-ACS free of MACE+ (P = 0.01) but persisted high in those with MACE+.

CONCLUSION

This study demonstrates a distinct inflammatory response and a lower risk of MACE+ following IFC-ACS. These findings advance our understanding of inflammatory cascades associated with different mechanisms of plaque disruption and provide hypothesis generating data for personalized anti-inflammatory therapeutic allocation to ACS patients, a strategy that merits evaluation in future clinical trials.

Investigations in plaque erosion and ruptured in acute coronary syndromes via novel methods in multimodal and VDJ sequencing

Background

Acute coronary syndromes (ACS) remain the most devastating clinical manifestation of cardiovascular disease, the most common cause of global mortality. ACS frequently arises from rupture of the coronary fibrous cap, in which a highly thrombogenic necrotic core is exposed to circulating blood, thereby triggering thrombus formation and impairing myocardial perfusion. While inflammation has been implicated as a key mechanism contributing to atherosclerotic plaque vulnerability and rupture, the underlying mechanisms leading to coronary plaque erosion, another form of ACS, are not well understood. In recent findings, flow cytometric (FACS) analysis of blood from the site of patients with culprit lesion plaque erosion showed significant enrichment of both CD4+ and CD8+ T-lymphocytes (+8.1% and +11.2%, respectively, both P&lt;0.05) as well as effector molecules such as granzyme A (+22.4%), perforin (+58.8%), and granulysin (+75.4%) as compared with patients with plaque rupture culprit lesion. The proximity of eroded lesions to coronary bifurcations seen by optical coherence tomography provides further elucidations linking shear stress alterations to the occurrence of erosional ACS.

Purpose

We aim to further explore the underlying immune cell mechanisms of coronary plaque erosion via a novel single cell multi-omic approach, never before established from samples aspirated from the arterial sheath.

Methods

Patients presenting with Myocardial Infarction underwent emergent coronary angiography & percutaneous coronary intervention. Infarction was characterized as either coronary plaque rupture or erosion by optical coherence tomography, in which then blood samples were obtained by being aspirated directly along the arterial sheath. Peripheral blood mononuclear cells were isolated via density gradient within four hours of sample aspiration and cryopreserved. Samples from 24 patients were promptly thawed, washed and incubated with 137 oligonucleotide barcoded antibodies to detect surface protein expression as well as a cellular hashtag antibody. Bioinformatic integration of single cell epitope and transcriptome information was performed derived from custom pipelines.

Results

Our analysis found 32 unique leukocyte clusters that allowed us to rigorously compare each patients sequenced single cell data -totaling approximately 140,000 singe cells. Additionally, the discovery of T cell oligoclonality amongst certain disease patients alludes to antigen-specific activation. We also observed increased CCL4 expression in CD8+ T-lymphocytes within erosional ACS.

Conclusion

Our high-parametric immune cell analysis shows distinct differences in the adaptive immune system, particularly CD8+ T-lymphocytes and their effector molecules, in the pathogenesis of erosional versus ruptured ACS. Furthermore, our observations found on the oligoclonal expansion of T cell clones aids us to further elucidate underlying mechanisms of culprit lesion formation in ACS.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): DGK - German Cardiac SocietyDGF - TRR 259 Aortic Disease German Research Foundation

[Who visits an ophthalmologist and how often? Results of the German nationwide adult health survey (DEGS1)]

BACKGROUND

The prevalence of eye diseases increases in the second half of life, especially cataract, glaucoma and age-related macular degeneration. In this study we examined the influencing factors for visiting an ophthalmologist in the last 12 months.

METHODS

Visits to an ophthalmologist's practice in the last 12 months and the frequency were surveyed in the German nationwide adult health survey wave 1 (DEGS1) study (baseline examination from 2008 to 2011, N = 7987, 52.6% women, age 18-79 years). Data on utilization were processed by taking the complex study design into consideration. Multivariable logistic regression analysis was used to determine associated factors including age, sex, socioeconomic status, place of residence, type of health insurance (e.g. statutory or private) and diabetes.

RESULTS

Between the ages of 18 and 79 years, 29.3% of survey participants in Germany visited an ophthalmologist in the last year, while after the age of 60 years this was only 50.4%. Multivariable logistic regression analysis showed an association with female sex (odds ratio OR = 1.51, p < 0.001), older age, type of health insurance (private vs. statutory: OR = 0.77, p = 0.006) and diabetes (OR = 3.84, p < 0.001), but no association with socioeconomic status (p = 0.29) or place of residence (p = 0.06).

CONCLUSION

Approximately one third of the German population visit an ophthalmologist at least once a year. Especially diabetics showed a high utilization of ophthalmological consultations, which could be based on the interdisciplinary guidelines for early detection of diabetic eye complications.

[The relevance of individual health services in German ophthalmology]

INTRODUCTION

Individual health services (ihs) have gained importance in the German health-care system. This article describes the economic impact and the daily practice of individual health services from the perspective of ophthalmologists.

METHODS

An online survey to examine the role of individual health services in ophthalmology was sent to the members of the German Ophthalmological Society (DOG) and the Professional Association of Ophthalmologists in Germany (BVA). 1,361 ophthalmologists (one fifth of all ophthalmologists in Germany) responded to the poll.

RESULTS

87.5 % of the ophthalmologists agree that the quality of ophthalmic care could suffer if the necessary individual health services were not performed. 78.9 % consider individual health services to be financially feasible for the patient. 65.6 % responded to be hardly able to survive economically without individual health services. For approximately half of the ophthalmologists, individual health services represent more than 10 % of their overall income. 57.5 % wish to abolish individual health services and to extend the service catalogue of the statutory health insurances.

DISCUSSION

In contrast to official reports about the benefit from individual health services, the ophthalmologists do see a medical need for individual health services. Obviously there is a discrepancy in the perspective between health insurers and ophthalmologists.

[Outcomes and health services research in ophthalmology]

This article describes the role of outcomes and health services research in the field of ophthalmology in Germany. First, the need for more information and data on the performance of ophthalmic care in Germany is explored. The concept, goals and methods of outcomes and health services research are explained and illustrated by examples of already existing research projects in ophthalmology. Future topics for research projects are highlighted. The article also describes how the field of outcomes and health services research can become a more important part within the scientific ophthalmological community in Germany.