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从稳定斑块到破裂与血栓

已审核发布 / Reviewed & published · 裁定 approved
From stable plaque to rupture & thrombosis审核 medical-reviewer· 2026-07-04· 引用核验 2026-07-04

斑块也分"脾气"：稳定还是易损​

在上一节里，我们看到动脉粥样硬化（atherosclerosis，Atherosclerosis动脉粥样硬化 · Atherosclerosis/ˌæθəroʊskləˈroʊsɪs/含胆固醇的脂质与炎症细胞在动脉内膜沉积、逐渐形成斑块使管腔狭窄、血管壁变硬的慢性过程。A chronic process in which cholesterol-rich lipids and inflammatory cells accumulate in the arterial intima, gradually forming plaques that narrow the lumen and stiffen the vessel wall.🧩 词根拆解 / word rootsathero-粥样、脂糊状（指斑块柔软的脂质核） · gruel/porridge (the soft fatty core)希腊语 athērē 粥/糊＋scler(o)-硬化、变硬 · hardening希腊语 sklēros 硬＋-osis（病理性）状态、过程 · abnormal condition/process希腊语 -ōsis）如何在动脉壁内一点点堆出斑块（atherosclerotic plaque，Atherosclerotic plaque动脉粥样硬化斑块 · Atherosclerotic plaque/ˌæθəroʊskləˈrɒtɪk plæk/动脉粥样硬化过程中在动脉内膜形成的局部病灶，由脂质坏死核心、纤维帽、平滑肌细胞与炎症细胞等组成；其结构（而非仅大小）决定它是否容易破裂惹祸。A focal lesion formed in the arterial intima during atherosclerosis, made up of a lipid necrotic core, a fibrous cap, smooth muscle cells and inflammatory cells; its structure (not just its size) determines how prone it is to rupture.🧩 词根拆解 / word rootsathero-粥样、脂糊状（指斑块柔软的脂质核） · gruel/porridge (the soft fatty core)希腊语 athērē 粥/糊＋scler(o)-硬化、变硬 · hardening希腊语 sklēros 硬＋plaque斑块、斑片 · a patch/plate法语 plaque 板/片）。

但并不是所有斑块都一样危险。真正决定一个斑块会不会突然"出事"的，不是它有多大、把血管堵得多窄，而是它的结构与成分。为了方便理解，病理学上常把斑块粗分为两类：相对安分的"稳定斑块"，和随时可能破裂惹祸的"易损斑块"（vulnerable plaque，Vulnerable plaque易损斑块 · Vulnerable plaque/ˈvʌlnərəbəl plæk/结构上容易破裂或侵蚀、从而突然引发血栓的斑块；最典型的一种是薄帽纤维粥样瘤（TCFA），特征为大脂质坏死核心、薄纤维帽并伴炎症。A plaque structurally prone to rupture or erosion and thus to suddenly triggering thrombosis; the archetype is the thin-cap fibroatheroma (TCFA), marked by a large lipid necrotic core, a thin fibrous cap and inflammation.🧩 词根拆解 / word rootsvulnerable易受伤的、脆弱的 · easily wounded/at risk拉丁语 vulnerare 使受伤＋plaque斑块、斑片 · a patch/plate法语 plaque 板/片）。

稳定斑块像什么样​

一个相对稳定的斑块（病理上称为纤维粥样斑块 fibroatheroma），其特征是：一个成熟的脂质坏死核心（necrotic core），外面覆盖着一层厚实、富含平滑肌细胞（smooth muscle cell）的纤维帽（fibrous cap）。[1]Tier 2Narula, Jagat et al. Histopathologic characteristics of atherosclerotic coronary disease and implications of the findings for the invasive and noninvasive detection of vulnerable plaques. Journal of the American College of Cardiology 2013doi:10.1016/j.jacc.2012.10.054

这里有两个关键结构。坏死核心（necrotic core，Necrotic core坏死核心 · Necrotic core/nəˈkrɒtɪk kɔːr/斑块中央由死亡细胞、胆固醇结晶与脂质等堆积而成的柔软脂质区；一旦暴露给血流，是高度致血栓的物质。The soft, lipid-rich region at the centre of a plaque built up from dead cells, cholesterol crystals and lipids; once exposed to flowing blood it is highly thrombogenic material.🧩 词根拆解 / word rootsnecr(o)-死亡、坏死 · death希腊语 nekros 死者＋-otic…性的（形容词后缀） · pertaining to (adjective suffix)＋core核心、中心 · the centre拉丁语 cor 心/核心）是斑块中央由死亡细胞、胆固醇结晶等堆积而成的脂质"糊"；纤维帽（fibrous cap，Fibrous cap纤维帽 · Fibrous cap/ˈfaɪbrəs kæp/覆盖在斑块脂质坏死核心之上、把核心与血流隔开的一层纤维结构，主要由平滑肌细胞及其分泌的胶原纤维构成；帽越厚越结实，斑块越稳定。The fibrous layer overlying a plaque's lipid necrotic core that separates the core from flowing blood, made mainly of smooth muscle cells and the collagen they secrete; a thicker, sturdier cap means a more stable plaque.🧩 词根拆解 / word rootsfibr-纤维 · fibre拉丁语 fibra 纤维＋-ous富含…的（形容词后缀） · full of / adjective suffix＋cap帽、盖 · cap/cover拉丁语 cappa 头罩）则是把这团东西和流动血液隔开的一层纤维"盖子"，主要由平滑肌细胞和它们分泌的胶原纤维构成。[1]Tier 2Narula, Jagat et al. Histopathologic characteristics of atherosclerotic coronary disease and implications of the findings for the invasive and noninvasive detection of vulnerable plaques. Journal of the American College of Cardiology 2013doi:10.1016/j.jacc.2012.10.054 帽子越厚、越结实，核心就越不容易接触到血液——这正是"稳定"的含义。

易损斑块：又薄又"炸"的组合​

易损斑块中最典型、最容易破裂的一种，病理学上叫薄帽纤维粥样瘤（thin-cap fibroatheroma，TCFA薄帽纤维粥样瘤 · Thin-cap fibroatheromaTCFA/θɪn kæp ˌfaɪbroʊˌæθəˈroʊmə/最典型的一类易损斑块，特征为大的富含脂质坏死核心、一层薄纤维帽（破裂时通常 <65 μm）并伴炎症；被视为斑块破裂的前体病灶。The archetypal vulnerable plaque, characterised by a large lipid-rich necrotic core, a thin fibrous cap (typically <65 μm in ruptured plaques) and inflammation; regarded as the precursor lesion to plaque rupture.🧩 词根拆解 / word rootsthin-cap薄帽 · thin cap＋fibro-纤维（性） · fibre/fibrous拉丁语 fibra 纤维＋athero-粥样、脂糊状 · gruel/porridge希腊语 athērē 粥/糊＋-oma瘤、增生性病灶 · tumour/mass-like lesion希腊语 -ōma，缩写 TCFA）。综述指出，TCFA 的特征是：一个大的富含脂质的坏死核心、一层薄薄的纤维帽，并伴有炎症（以及新生血管、斑块内出血、微钙化、血管正性重构等）。[2]Tier 2van Veelen, Anna et al. Detection of vulnerable coronary plaques using invasive and non-invasive imaging modalities. Journal of Clinical Medicine 2022doi:10.3390/jcm11051361

"薄"到什么程度算薄？综述指出，破裂斑块的纤维帽厚度通常小于 65 微米（μm）。[2]Tier 2van Veelen, Anna et al. Detection of vulnerable coronary plaques using invasive and non-invasive imaging modalities. Journal of Clinical Medicine 2022doi:10.3390/jcm11051361 作为对比，一份病理研究发现破裂处的纤维帽厚度多在 55 μm 以下，而稳定的纤维粥样斑块其帽厚都在 84 μm 以上。[1]Tier 2Narula, Jagat et al. Histopathologic characteristics of atherosclerotic coronary disease and implications of the findings for the invasive and noninvasive detection of vulnerable plaques. Journal of the American College of Cardiology 2013doi:10.1016/j.jacc.2012.10.054 换句话说，一层比头发丝还细得多的"盖子"，就是急性事件与平安之间的分界。

稳定斑块与易损斑块对比

图 · 稳定斑块（厚纤维帽、小脂核）不易破；易损斑块（薄帽、大坏死核、伴炎症）易破裂并在管腔内形成血栓。[1]Tier 2Narula, Jagat et al. Histopathologic characteristics of atherosclerotic coronary disease and implications of the findings for the invasive and noninvasive detection of vulnerable plaques. Journal of the American College of Cardiology 2013doi:10.1016/j.jacc.2012.10.054[2]Tier 2van Veelen, Anna et al. Detection of vulnerable coronary plaques using invasive and non-invasive imaging modalities. Journal of Clinical Medicine 2022doi:10.3390/jcm11051361

纤维帽为什么会变薄​

纤维帽不是一夜之间变薄的，而是"入不敷出"的结果。综述描述了这个过程：随着坏死核心不断增大，纤维帽会因为平滑肌细胞的丢失以及巨噬细胞（macrophage）持续涌入、降解帽内基质而变薄。[2]Tier 2van Veelen, Anna et al. Detection of vulnerable coronary plaques using invasive and non-invasive imaging modalities. Journal of Clinical Medicine 2022doi:10.3390/jcm11051361

这里的关键是炎症。综述指出，斑块内的泡沫细胞（foam cell，吞满脂质的巨噬细胞）会分泌促炎酶和细胞因子，激活免疫系统、招募更多免疫细胞，进一步加剧炎症过程。[2]Tier 2van Veelen, Anna et al. Detection of vulnerable coronary plaques using invasive and non-invasive imaging modalities. Journal of Clinical Medicine 2022doi:10.3390/jcm11051361 一边是负责"修补加固"的平滑肌细胞在减少，一边是负责"拆解"帽子基质的巨噬细胞在增多——一进一出，帽子就越来越薄、越来越脆。

斑块破裂：致血栓物质"见光"​

当那层薄帽终于撑不住时，就发生斑块破裂（plaque rupture，Plaque rupture斑块破裂 · Plaque rupture/plæk ˈrʌptʃər/斑块的薄纤维帽被撕裂、脂质坏死核心暴露给血流的事件；病理上定义为急性管腔内血栓经破裂的纤维帽与下方坏死核心相连通，是急性冠脉综合征最常见的原因。The event in which a plaque's thin fibrous cap tears and the lipid necrotic core is exposed to flowing blood; pathologically defined as an acute luminal thrombus connecting through the disrupted cap to the underlying necrotic core, and the most common cause of acute coronary syndrome.🧩 词根拆解 / word rootsplaque斑块、斑片 · a patch/plate法语 plaque 板/片＋rupt-破、裂 · to break/burst拉丁语 rumpere 破裂＋-ure…的行为/结果（名词后缀） · act/result of (noun suffix)）。病理上，破裂斑块被定义为：一个急性的管腔内血栓，通过被撕开的薄纤维帽，与下方富含脂质的坏死核心相连通。[1]Tier 2Narula, Jagat et al. Histopathologic characteristics of atherosclerotic coronary disease and implications of the findings for the invasive and noninvasive detection of vulnerable plaques. Journal of the American College of Cardiology 2013doi:10.1016/j.jacc.2012.10.054

为什么破裂会立刻招来血栓？因为帽子一破，原本被隔开的坏死核心就直接暴露给血流。教科书式资料指出，纤维帽破裂后，内部的坏死核心暴露到动脉管腔，这种高度致血栓的内皮下基质与循环中的血小板和白细胞接触，会激活凝血级联反应。[3]Tier 3Buja, L. Maximilian et al. Coronary Artery Thrombus. 2023https://www.ncbi.nlm.nih.gov/books/NBK534808/

于是就发生了血栓形成（thrombosis，Thrombosis血栓形成 · Thrombosis/θrɒmˈboʊsɪs/血液在血管内异常凝结、形成血凝块（血栓）的过程；在冠状动脉内急性发生时可堵塞血流、引发急性冠脉综合征。The process by which blood abnormally clots inside a vessel to form a clot (thrombus); when it happens acutely in a coronary artery it can block blood flow and trigger acute coronary syndrome.🧩 词根拆解 / word rootsthromb-血块、血栓 · blood clot希腊语 thrombos 凝块＋-osis（病理性）状态、过程 · abnormal condition/process希腊语 -ōsis）——血液在血管内凝结、形成血凝块（即血栓，thrombus，Thrombus血栓 · Thrombus/ˈθrɒmbəs/血栓形成过程中在血管内堆积起来的血凝块，由血小板、纤维蛋白及血细胞组成；破裂处多为富含红细胞的红色血栓，侵蚀处多为富含血小板的白色血栓。The blood clot that builds up inside a vessel during thrombosis, made of platelets, fibrin and blood cells; ruptures tend to form red-cell-rich 'red thrombus' and erosions platelet-rich 'white thrombus'.🧩 词根拆解 / word rootsthromb-血块、血栓 · blood clot希腊语 thrombos 凝块＋-us（名词词尾） · noun ending (Latin)）的过程。可以这样理解：坏死核心就像被薄膜密封起来的强力"胶水"，帽子一破、胶水见血，血小板和凝血系统被瞬间点燃，血栓在破口处迅速堆起。

值得强调的是，斑块破裂并不罕见：病理尸检研究显示，斑块破裂是多达约 75% 急性冠脉综合征发作的原因。[1]Tier 2Narula, Jagat et al. Histopathologic characteristics of atherosclerotic coronary disease and implications of the findings for the invasive and noninvasive detection of vulnerable plaques. Journal of the American College of Cardiology 2013doi:10.1016/j.jacc.2012.10.054

斑块侵蚀：另一条通往血栓的路​

破裂不是斑块引发血栓的唯一方式。另一种机制叫斑块侵蚀（plaque erosion，Plaque erosion斑块侵蚀 · Plaque erosion/plæk ɪˈroʊʒən/不同于破裂的另一种致血栓机制：纤维帽保持完整而厚，只是表面局部内皮细胞丢失，即可在斑块表面形成以血小板为主的白色血栓；多见于较年轻者、吸烟者与女性。A thrombosis mechanism distinct from rupture: the fibrous cap stays intact and thick but the overlying endothelium is locally lost, allowing a platelet-rich white thrombus to form on the plaque surface; seen more often in younger people, smokers and women.🧩 词根拆解 / word rootsplaque斑块、斑片 · a patch/plate法语 plaque 板/片＋eros-侵蚀、磨损 · to gnaw/wear away拉丁语 erodere 蚕食＋-ion…的过程/结果（名词后缀） · process/result of (noun suffix)）。综述指出，与破裂不同，侵蚀斑块的纤维帽是完整而厚实的，只是表面局部的内皮细胞丢失了；侵蚀斑块表面主要是以血小板和纤维蛋白原为主的"白色血栓"。[4]Tier 2Luo, Xing et al. Plaque erosion: a distinctive pathological mechanism of acute coronary syndrome. Frontiers in Cardiovascular Medicine 2021doi:10.3389/fcvm.2021.711453

侵蚀更"偏爱"某些人群。综述指出，斑块侵蚀与年龄小于 50 岁、当前吸烟、缺乏其他冠心病危险因素显著相关，且在女性中最具预测性。[4]Tier 2Luo, Xing et al. Plaque erosion: a distinctive pathological mechanism of acute coronary syndrome. Frontiers in Cardiovascular Medicine 2021doi:10.3389/fcvm.2021.711453 它也并不少见：综述指出，约有三分之一的 ST 段抬高型心肌梗死（STEMI）并非由斑块破裂、而是由斑块侵蚀所致。[4]Tier 2Luo, Xing et al. Plaque erosion: a distinctive pathological mechanism of acute coronary syndrome. Frontiers in Cardiovascular Medicine 2021doi:10.3389/fcvm.2021.711453 这提醒我们，即使影像上看不到典型的"大破口"，也不代表没有风险。

血栓堵住冠状动脉，就是急性事件​

无论走破裂还是侵蚀这条路，终点都指向同一个危险：血栓在冠状动脉（coronary artery，Coronary artery冠状动脉 · Coronary artery/ˈkɔːrənəri ˈɑːrtəri/从主动脉根部发出、环绕并深入心脏、专门为心肌自身供应含氧血液的动脉；一旦被斑块阻塞，就可能引发冠心病或心肌梗死。An artery arising from the root of the aorta that encircles and penetrates the heart to supply oxygen-rich blood to the heart muscle itself; blockage can cause coronary heart disease or heart attack.🧩 词根拆解 / word rootscoron-冠、王冠（冠状动脉像王冠一样环绕心脏） · crown (the arteries encircle the heart like a crown)拉丁语 corona 王冠＋-ary…的（形容词后缀） · adjective suffix＋artery动脉 · artery希腊语 artēria）里迅速长大，把血流堵住。教科书式资料指出，急性心肌梗死和不稳定型心绞痛的发病机制，正是冠状动脉斑块破裂导致冠状动脉急性血栓性闭塞。[3]Tier 3Buja, L. Maximilian et al. Coronary Artery Thrombus. 2023https://www.ncbi.nlm.nih.gov/books/NBK534808/

临床上，这一系列急性表现被统称为急性冠脉综合征（acute coronary syndrome，ACS急性冠脉综合征 · Acute coronary syndromeACS/əˈkjuːt ˈkɔːrənəri ˈsɪndroʊm/冠状动脉内急性血栓性闭塞引起的一组急性临床表现的总称，包括 ST 段抬高型心肌梗死（STEMI）、非 ST 段抬高型心肌梗死（NSTEMI）和不稳定型心绞痛。An umbrella term for the acute clinical presentations caused by acute thrombotic occlusion of a coronary artery, including ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI) and unstable angina.🧩 词根拆解 / word rootsacute急性的、突然的 · sharp/sudden拉丁语 acutus 尖锐的＋coron-冠、王冠（冠状动脉） · crown (the coronary arteries)拉丁语 corona 王冠＋syndrome综合征（同时出现的一组表现） · a set of features running together希腊语 syn- 一起 + dromos 奔跑，缩写 ACS），包括 ST 段抬高型心肌梗死（STEMI）、非 ST 段抬高型心肌梗死（NSTEMI）以及不稳定型心绞痛。[3]Tier 3Buja, L. Maximilian et al. Coronary Artery Thrombus. 2023https://www.ncbi.nlm.nih.gov/books/NBK534808/ 也就是说，几十年缓慢积累的斑块，可能因为一次破裂或侵蚀，在很短时间内演变成心肌梗死。

小结​

  • 斑块危险与否，主要看结构：稳定斑块有厚实、富含平滑肌细胞的纤维帽盖住坏死核心；易损斑块（TCFA）则是大脂质坏死核心 + 薄纤维帽 + 炎症。[1]Tier 2Narula, Jagat et al. Histopathologic characteristics of atherosclerotic coronary disease and implications of the findings for the invasive and noninvasive detection of vulnerable plaques. Journal of the American College of Cardiology 2013doi:10.1016/j.jacc.2012.10.054[2]Tier 2van Veelen, Anna et al. Detection of vulnerable coronary plaques using invasive and non-invasive imaging modalities. Journal of Clinical Medicine 2022doi:10.3390/jcm11051361
  • 纤维帽变薄，是坏死核心增大、平滑肌细胞丢失、巨噬细胞与炎症降解帽内基质共同作用的结果。[2]Tier 2van Veelen, Anna et al. Detection of vulnerable coronary plaques using invasive and non-invasive imaging modalities. Journal of Clinical Medicine 2022doi:10.3390/jcm11051361
  • 斑块破裂会让致血栓的坏死核心暴露、激活凝血、形成血栓；侵蚀则是纤维帽完整、内皮丢失也能长出（以血小板为主的）血栓。[3]Tier 3Buja, L. Maximilian et al. Coronary Artery Thrombus. 2023https://www.ncbi.nlm.nih.gov/books/NBK534808/[4]Tier 2Luo, Xing et al. Plaque erosion: a distinctive pathological mechanism of acute coronary syndrome. Frontiers in Cardiovascular Medicine 2021doi:10.3389/fcvm.2021.711453
  • 冠状动脉内急性血栓堵塞，临床上表现为急性冠脉综合征（心肌梗死、不稳定型心绞痛等）。[3]Tier 3Buja, L. Maximilian et al. Coronary Artery Thrombus. 2023https://www.ncbi.nlm.nih.gov/books/NBK534808/

⚕️ 本内容仅供健康科普与学习，不能替代专业医疗建议、诊断或治疗。

参考文献 / References​

  1. Tier 2Narula, Jagat et al. Histopathologic characteristics of atherosclerotic coronary disease and implications of the findings for the invasive and noninvasive detection of vulnerable plaques. Journal of the American College of Cardiology (2013) · doi:10.1016/j.jacc.2012.10.054
  2. Tier 2van Veelen, Anna et al. Detection of vulnerable coronary plaques using invasive and non-invasive imaging modalities. Journal of Clinical Medicine (2022) · doi:10.3390/jcm11051361
  3. Tier 3Buja, L. Maximilian et al. Coronary Artery Thrombus (2023) · link
  4. Tier 2Luo, Xing et al. Plaque erosion: a distinctive pathological mechanism of acute coronary syndrome. Frontiers in Cardiovascular Medicine (2021) · doi:10.3389/fcvm.2021.711453