Plaque Characteristics in Culprit Lesionsand Inflammatory Status in Diabetic Acute Coronary Syndrome PatientsYoung Joon Hong, MD, PHD, Myung Ho Jeong, MD, PHD, FACC, FAHA, FESC, FSCAI, Yun Ha Choi, RN, Jum Suk Ko, MD, Min Goo Lee, MD, Won Yu Kang, MD, Shin Eun Lee, MD, Soo Hyun Kim, MD, Keun Ho Park, MD, Doo Sun Sim, MD, Nam Sik Yoon, MD, Hyun Ju Yoon, MD, Kye Hun Kim, MD, PHD, Hyung Wook Park, MD, PHD, Ju Han Kim, MD, PHD, Youngkeun Ahn, MD, PHD, FACC, FSCAI, Jeong Gwan Cho, MD, PHD, FACC, Jong Chun Park, MD, PHD, Jung Chaee Kang, MD, PHDGwangju, KoreaO B J E C T I V E SThe aim of this study was to assess the plaque characteristics in culprit lesions in diabetic patients with acute coronary syndrome (ACS).B A C K G R O U N DData of the relationship between diabetes mellitus and plaque characteristics in patients with ACS are lacking.M E T H O D SWe performed grayscale intravascular ultrasound (IVUS) analysis in 422 ACS patients and virtual histology (VH)-IVUS in 310 ACS patients. By subgroup analysis, 112 patients with acute myocardial infarction (AMI) with plaque ruptures also were evaluated.R E S U L T SIn the diabetic subgroup, high-sensitivity C-reactive protein (hs-CRP) was significantly increased (p ? 0.008), multivessel disease was more common (65% vs. 29%, p ? 0.001), and plaque burden was greater (79.7 ? 9.8 mm2vs. 74.2 ? 8.9 mm2, p ? 0.001). In the subgroup analysis of 112 AMI patients with plaque ruptures, the presence of multiple plaque ruptures (60% vs. 29%, p ? 0.001) and thrombus (72% vs. 52%, p ? 0.032) were more common in diabetic group. Diabetes mellitus wasthe independent predictor of hs-CRP elevation (odds ratio OR: 3.030, 95% confidence interval CI: 1.204 to 7.623, p ? 0.019), and multiple plaque ruptures (OR: 2.984, 95% CI: 1.311 to 6.792, p ? 0.009) by multivariable analysis. In 310 VH-IVUS subsets, the absolute and percent necrotic core volumes weresignificantly greater (16.9 ? 15.1 mm3vs. 11.5 ? 11.4 mm3, p ? 0.001, and 17.3 ? 9.4% vs. 13.7 ? 7.5%,p ? 0.001, respectively), and the presence of at least one thin-cap fibroatheroma (TCFA) (60% vs. 42%, p ? 0.003) and multiple TCFAs (28% vs. 11%, p ? 0.001) were more common in the diabetic group. Diabetes mellitus was the only independent predictor of TCFA by multivariable analysis (OR: 2.139, 95% CI: 1.266 to 3.613, p ? 0.004).C O N C L U S I O N SDiabetic patients with ACS have more plaques with characteristics of plaquevulnerability, different composition of plaques, and have increased inflammatory status compared with nondiabetic patients with ACS.(J Am Coll Cardiol Img 2009;2:33949) 2009 by the American College of Cardiology FoundationFrom the Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea.Manuscript received July 9, 2008, accepted October 30, 2008.J A C C : C A R D I O V A S C U L A R I M A G I N GV O L . 2 , N O . 3 , 2 0 0 9 2 0 0 9 B Y T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y F O U N D A T I O NI S S N 1 9 3 6 - 8 7 8 X / 0 9 / $ 3 6 . 0 0P U B L I S H E D B Y E L S E V I E R I N C .D O I : 1 0 . 1 0 1 6 / j . j c m g . 2 0 0 8 . 1 0 . 0 1 7Autopsy studies have shown that acute myocar- dial infarction (AMI) results from spontane- ous plaque rupture or erosion and subse- quent thrombosis (1,2). Intravascular ultrasound (IVUS) studies have reported culprit- lesion ruptured plaques in a varying percentage of patients with acute coronary syndrome (ACS)(37). There is a strong inflammatory response to the tissue injury that occurs during an AMI, andplaque rupture and the degree of the inflammatory response might be an important determinant of the clinical outcome (8). Several studies have demon- strated an association between elevated C-reactive protein (CRP) levels and culprit lesion ruptured plaques in patients with AMI (5,7,9). C-reactive protein has emerged as a simple tool for detecting systemic in-flammation in patients with subsequent coronary events (10,11). Recently, several virtual histology (VH)-IVUS studies have demonstrated the coronary plaque compo- nents in patients with ACS (1214). In a study of sudden death due to coronary thrombosis, Davies (15) reported that rupture accounted for 84% of thrombi in 134 men without diabetes and that rupture was found in 59% in 27 women without diabetes, whereas only 34% of thrombi were due to rupture in 41 patients with diabetes mellitus (men and women). However, another pathological study showed diabetic patients had a greateramount of macrophage-infiltrated lipid- rich plaques compared with nondiabeticpatients (16). This means specific IVUSand VH-IVUS findings could be identi-fied in diabetic patients. However, no studies have demonstrated a relationshipbetween diabetes mellitus and inflamma- tory response indicated by CRP versus plaque characteristics, including plaquecomposition and the incidence of thin-cap fibro- atheroma (TCFA) in patients with ACS. There- for