Vol 29, No 2 (2022)
Image in Cardiovascular Medicine
Published online: 2022-04-07

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IMAGE IN CARDIOVASCULAR MEDICINE

interventionAL CARDIOLOGY

Cardiology Journal 2022, Vol. 29, No. 2, 362–363

DOI: 10.5603/CJ.2022.0018

Copyright © 2022 Via Medica

ISSN 1897–5593 eISSN 1898018X

Vulnerable plaque derived from aspirated thrombi in recurrent acute coronary syndrome with familial hypercholesterolemia despite intensive lipid-lowering statin therapy

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Hiroyuki Natsui1Takao Konishi1Kohei Saiin1Youji Tamaki1Tomoya Sato1Sakae Takenaka1Atsushi Tada1Yoshifumi Mizuguchi1Yuta Kobayashi1Takuma Sato1Rui Kamada1Kiwamu Kamiya1Toshiyuki Nagai1Shinya Tanaka2Toshihisa Anzai1
1Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
2Department of Cancer Pathology, Faculty of Medicine, Hokkaido University, Sapporo, Japan

Address for correspondence: Takao Konishi, MD, PhD, Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, West 7, North 15, Kita-ku, Sapporo, 060-8638, Japan, tel: +81-11-706-6973, fax: +81-11-706-7874, e-mail: takaokonishi0915@gmail.com

Received: 2.06.2021 Accepted: 11.10.2021

This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

A 35-year-old man was admitted to our hospital due to acute coronary syndrome (ACS). One year before, he was diagnosed with familial hypercholesterolemia (FH), and a stent was implanted in his left anterior descending artery and the left circumflex artery due to ACS. Despite receiving combination therapy of rosuvastatin 20 mg/day and ezetimibe 10 mg/day, his low-density lipoprotein cholesterol (LDL-C) concentration was 100 mg/dL at the second ACS. Emergency coronary angiography (CAG) revealed total occlusion of the middle right coronary artery (Fig. 1A). An intravascular ultrasound study suggested plaque rupture (Fig. 1B, arrow). Aspiration thrombectomy and stent implantation facilitated a grade 3 Thrombolysis in Myocardial Infarction flow in the final CAG. Histopathological examination of the aspirated thrombi showed a luminal thrombus (arrowhead) communicating with the underlying necrotic core with numerous cholesterol clefts (Fig. 1C-a). Inflammatory cells, including foamy and hemosiderin-laden macrophages, were also observed (Fig. 1C-b). These findings suggest that intensive lipid-lowering therapy using statin and ezetimibe was insufficient to stabilize the vulnerable plaque in a patient with FH when the targeted LDL-C level was not achieved. No further ACS has been documented after administration of proprotein convertase subtilisin/kexin type 9 inhibitor for secondary prevention over a 14-month follow-up.

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Figure 1. A. The initial coronary angiogram; B. The intravascular ultrasound study; C. Histopathology of aspirated thrombi showing (a) cholesterol clefts and (b) inflammatory cells including foamy and hemosiderin-laden macrophages.

Conflict of interest: None declared