(Circulation. 1999;100:e121.)
© 1999 American Heart Association, Inc.
Circulation Electronic Pages |
Coronary Pressure
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Introduction |
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Nico Pijls and Bernard DeBruyne. 339 pp, illustrated. Dordrect, The Netherlands: Kluwer Academic Publishers; 1997.
To review this important book in proper perspective, a substantive preamble is useful for understanding its major contributions to the pathophysiology of coronary artery stenoses.
Although coronary arteriography is the central diagnostic tool of cardiovascular medicine, the limitations of coronary arteriography need to be recognized and new invasive technologies explored in order to advance our knowledge and improve clinical management of patients.
New knowledge about mechanisms of plaque rupture from heterogeneous diffuse coronary atherosclerosis and benefits of lipid lowering require revisions in our traditional use of cardiac catheterization and coronary arteriography. This new knowledge can be summarized as follows:
1. Eighty-five percent of myocardial infarctions develop at sites of relatively less severely narrowed, lipid-rich plaques that rupture with thrombosis and spasm.
2. Coronary atherosclerosis is diffuse and subject to plaque rupture throughout the length of the epicardial coronary artery.
3. The diagnostic accuracy of coronary arteriography for diffuse coronary atherosclerosis is poor, as low as 10% to 20%, compared with intracoronary ultrasound.
4. Recent trials raise serious questions about the value of arteriographic-based interventions, particularly the lack of improved survival, their failure to reduce myocardial infarctions, or the observed greater mortality and myocardial infarctions in revascularized patients compared with medically treated patients, as reported in the RITA-2, VANQWISH and AVERT Trials, in the Duke clinical database and in the Canadian experience.
5. Vigorous cholesterol lowering markedly reduces
cardiac events and mortality more than invasive procedures