Preventing future acute coronary events: is the target the so-called vulnerable plaque or the high-risk or vulnerable...

Heart disease still remains the leading cause of mortality in the USA in spite of recent reductions in the death rate; complications of coronary artery disease and its sequelae are the most common mechanism of demise. Although there have been great advances in the prevention and treatment of acute myocardial infarction, greater emphasis on prevention will likely be needed to reduce acute coronary complications further.

The literature is replete with articles on the attempted localization of so-called vulnerable plaques and vulnerable, or high-risk patients. They emphasize the importance of the identification of that high-risk plaque or high-risk individual prior to a subsequent coronary event. This article highlights the breakthroughs into the pathophysiology of acute coronary syndromes in the past few decades and presents a perspective on current treatments, improved risk stratification and potential technological advances that may impact diagnosis and management.

Unfortunately, the search for the so-called vulnerable plaque is hampered by the lack of both natural history studies and proven local or regional therapies for these otherwise asymptomatic plaques. Thus, emphasis on the vulnerable or high-risk patient is appropriate, but identifying these individuals in primary prevention is also fraught with difficulty. No specific recommendations can be made at present, as more data are needed in both areas. However, guidelines for future advances are proposed.