PATIENT WITH CHRONIC CORONARY SYNDROME: USE OF MULTIMODAL IMAGING FOR CORRECT DIAGNOSIS AND TREATMENT

Abstract

Abstract In the context of CCS, CCTA allows us to discriminate with almost certainty between patients with the absence of disease. In case of a positive test, the characteristics of the plaque allow to stratified risk of developing future events. In doubtful cases it is necessary to resort to a multimodal imaging strategy for the correct diagnosis. We present the case of a 63-year-old hypertensive and dyslipidemic man who started presenting two months ago episodes of asthenia associated with tachycardia and jugular constriction after taking the usual CCB therapy. With a pre-test probability of 26%, a CCTA scan was requested which highlighted a non-calcific fibrous plaque (Image 1) at the level of the middle circumflex inducing a moderate stenosis (Cad-Rads 3). The patient underwent coronary angiography which confirmed this lesion and also highlighted a similar one downstream of the first. (Image 2) The OCT evaluation showed: 7 mm eccentric fibrous proximal plaque with evidence of multiple intimal layers (Healed plaque) in its distal third and with evidence of a medial-intimal flap involving three quadrants in the proximal two thirds (270°), with current intact endothelium and presence of neo-angiogenesis; MLA 2.33 mm² and AS 70%. Picture compatible with healed spontaneous dissection of the vessel. (Image 3) The subsequent 12 mm concentric plaque (360° involvement of the vessel) had a predominantly lipid component with macrophages and fibrous cap of 60 µm, MLA of 2.3mm² and AS 72%. Panel compatible with high risk plaque. (Image 4) It was decided to implant a 3.5x26mm drug-eluting stent through OCT-guided PCI with final MSA of 7.62 mm², stent expansion of 81%, absence of dissections at the edges and residual distal edge plaque with MLA of 7.6 mm². (Image 5). Conclusions Healed plaques are more frequent in patients with CCS and represent a plaque complicated by medial-intimal ulceration subsequently healed by neo-endothelialization. On CCTA they appear as non-calcific fibrous plaques with an intermediate density expressed in Hounsfield Units but the definitive diagnosis can only be obtained using an Intravascular Imaging method (OCT in the case presented). The patient appears asymptomatic after resuming his usual antihypertensive therapy at 30-day FU.