(Circulation. 1996;94:2013-2020.)
© 1996 American Heart Association, Inc.
Articles |
Stability and Instability: Two Faces of Coronary Atherosclerosis
The Paul Dudley White Lecture 1995
St George's Hospital Medical School, University of London, UK.
Correspondence to Michael J. Davies, MD, Cardiovascular Pathology Unit, St George's Hospital Medical School, Cranmer Terrace, London SW17 ORE, UK.
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Introduction |
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Paul Dudley White was an astute observer of ischemic heart disease who emphasized the unity of acute myocardial infarction and chronic exertional angina as facets of the clinical expression of coronary atherosclerosis. He knew that plaque ulceration was a precipitator of thrombosis, but in the days before angiography was widely used, he reasoned that thrombosis occurred at sites of previous high-grade stenosis. He would be fascinated by the explosion of knowledge concerning the mechanisms of the two major expressions of coronary heart disease that has occurred since his death in 1973.
Any consideration of how symptoms arise in coronary atherosclerosis must begin with plaque. By early adult life, most individuals in developed countries will have some coronary plaques that, in pathological terms, are advanced. This simply means that within the plaque there has been considerable accumulation of extracellular lipid, lipid within foam cells of macrophage origin, and collagen produced by smooth muscle cells.
Plaques occupy space; yet, as pathology studies have shown in the past, the arterial lumen is not necessarily compromised, implying that the angiogram would be a poor tool to assess atherosclerosis in living subjects, however good it might be at detecting high-grade stenosis that causes symptoms. The insensitivity of angiography in the detection of plaques has been amply demonstrated by intravascular ultrasound.1 2 The landmark work of Glagov et al,3 which showed that the arterial wall is not a static, immutable structure but rather can remodel itself by increasing its external diameter to accommodate the plaque without narrowing
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M. E. Bertrand, M. L. Simoons, K. A.A. Fox, L. C. Wallentin, C. W. Hamm, E. McFadden, P. J. De Feyter, G. Specchia, and W. Ruzyllo Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation Eur. Heart J., December 1, 2002; 23(23): 1809 - 1840. [Full Text] [PDF]
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G. Ghilardi, M. L. Biondi, M. DeMonti, O. Turri, E. Guagnellini, and R. Scorza Matrix Metalloproteinase-1 and Matrix Metalloproteinase-3 Gene Promoter Polymorphisms Are Associated With Carotid Artery Stenosis Stroke, October 1, 2002; 33(10): 2408 - 2412. [Abstract] [Full Text] [PDF]
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 G. K. Hansson, P. Libby, U. Schonbeck, and Z.-Q. Yan Innate and Adaptive Immunity in the Pathogenesis of Atherosclerosis Circ. Res., August 23, 2002; 91(4): 281 - 291. [Abstract] [Full Text] [PDF]
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G. Rioufol, G. Finet, I. Ginon, X. Andre-Fouet, R. Rossi, E. Vialle, E. Desjoyaux, G. Convert, J.F. Huret, and A. Tabib Multiple Atherosclerotic Plaque Rupture in Acute Coronary Syndrome: A Three-Vessel Intravascular Ultrasound Study Circulation, August 13, 2002; 106(7): 804 - 808. [Abstract] [Full Text] [PDF]
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A. Tedgui and Z. Mallat Platelets in Atherosclerosis: A New Role for {beta}-Amyloid Peptide Beyond Alzheimer's Disease Circ. Res., June 14, 2002; 90(11): 1145 - 1146. [Full Text] [PDF]
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J.H.F. Rudd, E.A. Warburton, T.D. Fryer, H.A. Jones, J.C. Clark, N. Antoun, P. Johnstrom, A.P. Davenport, P.J. Kirkpatrick, B.N. Arch, et al. Imaging Atherosclerotic Plaque Inflammation With [18F]-Fluorodeoxyglucose Positron Emission Tomography Circulation, June 11, 2002; 105(23): 2708 - 2711. [Abstract] [Full Text] [PDF]
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P. R. Moreno, K. R. Purushothaman, V. Fuster, and W. N. O'Connor Intimomedial Interface Damage and Adventitial Inflammation Is Increased Beneath Disrupted Atherosclerosis in the Aorta: Implications for Plaque Vulnerability Circulation, May 28, 2002; 105(21): 2504 - 2511. [Abstract] [Full Text] [PDF]
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C.L. de Korte, S.G. Carlier, F. Mastik, M.M. Doyley, A.F.W. van der Steen, P.W. Serruys, and N. Bom Morphological and mechanical information of coronary arteries obtained with intravascular elastography. Feasibility study in vivo Eur. Heart J., March 1, 2002; 23(5): 405 - 413. [Abstract] [Full Text] [PDF]
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B. Salobir, M. Sabovic, P. Peternel, and M. Stegnar Fibrinolytic Parameters and Lipoprotein(a) in Young Women with Myocardial Infarction Angiology, March 1, 2002; 53(2): 157 - 163. [Abstract] [PDF]
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 A. Farzaneh-Far, J. Rudd, and P. L Weissberg Inflammatory mechanisms: Ischaemic heart disease Br. Med. Bull., October 1, 2001; 59(1): 55 - 68. [Abstract] [Full Text] [PDF]
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X.-Q. Zhao, C. Yuan, T. S. Hatsukami, E. H. Frechette, X.-J. Kang, K. R. Maravilla, and B. G. Brown Effects of Prolonged Intensive Lipid-Lowering Therapy on the Characteristics of Carotid Atherosclerotic Plaques In Vivo by MRI: A Case-Control Study Arterioscler Thromb Vasc Biol, October 1, 2001; 21(10): 1623 - 1629. [Abstract] [Full Text] [PDF]
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S. W.E. van de Poll, T. J. Romer, O. L. Volger, D. J.M. Delsing, T. C. Bakker Schut, H. M.G. Princen, L. M. Havekes, J. W. Jukema, A. van der Laarse, and G. J. Puppels Raman Spectroscopic Evaluation of the Effects of Diet and Lipid-Lowering Therapy on Atherosclerotic Plaque Development in Mice Arterioscler Thromb Vasc Biol, October 1, 2001; 21(10): 1630 - 1635. [Abstract] [Full Text] [PDF]
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E.G. Zouridakis, R. Schwartzman, X. Garcia-Moll, I.D. Cox, S. Fredericks, D.W. Holt, and J.C. Kaski Increased plasma endothelin levels in angina patients with rapid coronary artery disease progression Eur. Heart J., September 1, 2001; 22(17): 1578 - 1584. [Abstract] [PDF]
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J S Sidhu and J C Kaski Peroxisome proliferator activated receptor {gamma}: a potential therapeutic target in the management of ischaemic heart disease Heart, September 1, 2001; 86(3): 255 - 258. [Full Text] [PDF]
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P. Amarenco Hypercholesterolemia, lipid-lowering agents, and the risk for brain infarction Neurology, September 1, 2001; 57(90002): S35 - 44. [Abstract] [Full Text]
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D. A. Smith, S. D. Irving, J. Sheldon, D. Cole, and J. C. Kaski Serum Levels of the Antiinflammatory Cytokine Interleukin-10 Are Decreased in Patients With Unstable Angina Circulation, August 14, 2001; 104(7): 746 - 749. [Abstract] [Full Text] [PDF]
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M. Schartl, W. Bocksch, D. H. Koschyk, W. Voelker, K. R. Karsch, J. Kreuzer, D. Hausmann, S. Beckmann, and M. Gross Use of Intravascular Ultrasound to Compare Effects of Different Strategies of Lipid-Lowering Therapy on Plaque Volume and Composition in Patients With Coronary Artery Disease Circulation, July 24, 2001; 104(4): 387 - 392. [Abstract] [Full Text] [PDF]
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P. Libby Current Concepts of the Pathogenesis of the Acute Coronary Syndromes Circulation, July 17, 2001; 104(3): 365 - 372. [Full Text] [PDF]
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