(Circulation. 1997;96:1360-1362.)
© 1997 American Heart Association, Inc.
Articles |
Lipid Lowering Versus Revascularization
An Idea Whose Time (For Testing) Has Come*
From Cedars-Sinai Medical Center, Los Angeles, Calif.
Correspondence to James S. Forrester, MD, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Room 5314 North Tower, Los Angeles, CA 90048-1865. E-mail forrester{at}csmc.edu
Abstract There is strong evidence that
revascularization does not prevent myocardial
infarction in patients with stable coronary artery disease
(CAD). The anatomic basis for this counterintuitive conclusion seems to
be that most myocardial infarctions occur at sites that did not
previously exhibit an angiographically significant stenosis.
These angiographic observations are further supported by thallium
studies in stable CAD that demonstrate that the site of stress-induced
ischemia is frequently not the site of subsequent myocardial
infarction. Since both coronary artery bypass graft surgery and
percutaneous transluminal coronary angioplasty
are directed at more severe coronary stenoses, we are
led to the remarkable conclusion that angiography does not identify,
and consequently revascularization therapies do not
treat, the lesions that lead to myocardial infarction. The pathology of
coronary atherosclerosis provides the basis for
understanding why revascularization does not
prevent infarction: unstable lesions that cause infarction are not
necessarily severely stenotic, and stenotic lesions are
not necessarily unstable. In contrast to
revascularization, lipid lowering reduces the rate
of myocardial infarction by 
30% over a period of 5 years. Thus, we
might postulate that lipid lowering is the more effective therapy for
both prevention of acute myocardial infarction and long-term survival.
The health policy and economic implications of this viewpoint, should
it emerge in the management of coronary heart disease, are
clearly substantial. Consequently, the relative roles of lipid-lowering
therapy and revascularization, both alone and
together, must now be determined. It is an idea whose time—for
testing—has come.
Key Words: myocardial infarction • lipids • angina • atherosclerosis
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