Significance and Management of Ulcerative Plaque
Ulcerative plaque represents a significant marker of plaque instability and is associated with increased risk of thromboembolic events, requiring prompt evaluation and appropriate management based on location and clinical context.
Cardiovascular Ulcerative Plaque
Clinical Significance
- Ulcerated atherosclerotic plaques form the substrate for the vast majority of coronary thrombi 1
- Plaque ulceration indicates previous plaque rupture and is strongly associated with thromboembolic events 2, 3
- In carotid arteries, ulcerated plaques with echolucency have a 9.34 times higher risk of thromboembolic cerebrovascular events 4
- Ulcerated plaques may exist chronically for weeks to months without resolving 1
Risk Factors and Composition
- Large atherosclerotic plaques with intraplaque hemorrhage and lipid-rich necrotic cores are most likely to develop ulceration 2
- Plaque composition predictors of ulceration include:
- Increased vessel wall volume
- Higher relative lipid-rich necrotic core
- Higher relative intraplaque hemorrhage volume
- Thin or ruptured fibrous cap 2
Management in Coronary Arteries
- Visualization of a culprit ulcerated plaque requires immediate attention, even in vessels with less than 50% stenosis 5
- For high-risk patients (elevated troponin, CRP, or BNP), an early invasive strategy is recommended 5
- For severe 3-vessel stenosis with reduced left ventricular function or left main stenosis with ulceration, early CABG should be considered 5
Management in Carotid Arteries
- Urgent vascular imaging is indicated when ulcerated carotid plaque is detected 6
- Antiplatelet therapy should be initiated unless contraindicated 6
- Consider revascularization (endovascular vs. bypass) based on:
- Morphological distribution of disease
- Patient comorbidities
- Local expertise 6
- Regular duplex ultrasound surveillance at 1,3,6, and 12 months post-intervention 6
Gastrointestinal Ulcerative Plaque (Peptic Ulcer)
Clinical Significance
- Peptic ulceration occurs due to acid peptic damage to gastro-duodenal mucosa 5
- Lifetime prevalence in general population: 5-10% 5
- Annual incidence: 0.1-0.3% 5
- Complications occur in 10-20% of patients with peptic ulcer disease 5
Risk Factors
- Helicobacter pylori infection
- Extensive use of NSAIDs
- Alcohol consumption
- Smoking 5
Management
- Prompt recognition and resuscitation when required
- Appropriate antibiotic therapy (especially for H. pylori)
- Timely surgical/radiological treatment when indicated
- Acid suppression therapy 5
Dermatological Ulcerative Lesions
Pressure Ulcers
- Represent localized areas of tissue necrosis
- Typically polymicrobial when infected, including both aerobes and anaerobes 5
- Management includes:
- Surgical debridement of necrotic tissue
- Antibiotic therapy for severe infections or systemic signs
- Appropriate wound care to prevent recurrence 5
Ulcerated Infantile Hemangiomas
- Management focuses on:
- Wound care
- Pain control (acetaminophen, cautious use of topical 2.5% lidocaine)
- Control of hemangioma growth
- Propranolol therapy has shown success in treating ulceration
- Pulsed-dye laser therapy may be effective in refractory cases 5
Ulcerative Colitis
- Characterized by inflammation and ulceration of the colon and rectum
- Severe acute ulcerative colitis requires:
- IV fluid and electrolyte replacement
- Unprepared flexible sigmoidoscopy and biopsy
- Stool cultures and C. difficile toxin assay
- IV corticosteroids (methylprednisolone 60 mg/24h or hydrocortisone 100 mg QID)
- Subcutaneous prophylactic low-molecular-weight heparin
- Nutritional support if malnourished 5
Key Principles Across All Ulcerative Lesions
- Early identification and risk stratification
- Appropriate imaging to assess extent and characteristics
- Targeted therapy based on location and underlying cause
- Regular follow-up and surveillance
- Risk factor modification to prevent recurrence
Pitfalls and Caveats
- Ulcerated plaques may exist chronically without symptoms until a thrombotic event occurs
- Not all ulcerated plaques require immediate intervention; decision should be based on symptoms, location, and risk factors
- Inflammatory markers may be elevated in the presence of ulcerated plaques
- Women may have different outcomes with early revascularization compared to men in coronary disease 5
- Avoid debridement of purely ischemic ulcers without signs of infection 6