Myocardial infarction, stroke and arterial stenosis: time to reassess a major misunderstanding
1Department of Radiology, Azienda Ospedaliero-Universitaria di Cagliari, Polo di Monserrato, Cagliari, Italy.
Insights
Arterial stenosis severity does not reliably predict acute ischemic events like heart attack or stroke. Current guidelines overemphasize stenosis grading, neglecting plaque biology and pharmacological treatments for risk mitigation.
Area of Science:
- Cardiovascular Medicine
- Atherosclerosis Research
Background:
- A persistent misconception links arterial stenosis directly to acute ischemic events, including myocardial infarction and cerebral stroke.
- Current clinical guidelines often codify an approach based on the premise that occlusive arterial stenosis generally provokes ischemic events.
Purpose of the Study:
- To challenge the traditional reliance on stenosis grading for therapeutic decisions in cardiovascular disease.
- To highlight mechanistic differences between chronic ischemia and acute thrombotic events.
- To advocate for a shift towards modifying plaque biology over solely addressing stenosis.
Main Methods:
- Review of current clinical guidelines and their reliance on stenosis grading.
- Analysis of recent evidence, including a major clinical trial, on the correlation between stenosis severity and acute thrombotic complications.
- Examination of mechanistic differences between flow-limiting stenoses and acute atherothrombotic events.
Main Results:
- Evidence suggests a lack of strong correlation between stenosis severity and acute thrombotic complications of atherosclerosis.
- A significant proportion of major adverse cardiovascular events occur in individuals without obstructive coronary artery disease.
- Mechanistic differences exist between chronic/inducible ischemia and acute thrombotic events.
Conclusions:
- Traditional reliance on stenosis grading as a biomarker for therapeutic decision-making is questioned.
- A shift towards modifying plaque biology, rather than solely focusing on stenosis, is advocated.
- Pharmacological treatment should be a fundamental factor in cardiovascular risk mitigation.
Abstract:
A misconception persisting among the scientific and clinical communities relates to the correlation between arterial stenosis and acute ischaemic events, including myocardial infarction and cerebral stroke. This Perspective article challenges the approach that most of the current guidelines codify, which is based on the concept that occlusive arterial stenosis generally provokes ischaemic events. We highlight the mechanistic differences between chronic or inducible ischaemia caused by flow-limiting stenoses and acute thrombotic events and question the traditional reliance on stenosis grading as a biomarker for therapeutic decision-making that many guidelines enshrine. Furthermore, we review the latest evidence highlighting the lack of a correlation between stenosis severity and the occurrence of acute thrombotic complications of atherosclerosis, in the light of a major clinical trial that included a large contemporary population and showed that only one-third of major adverse cardiovascular events occur in individuals with obstructive coronary artery disease. These considerations aim to foster a shift, grounded in contemporary evidence, towards treatment approaches that address modifying plaque biology rather than stenoses per se, using pharmacological treatment as a fundamental factor in risk mitigation and moving away from sole reliance on stenosis grading as a primary determinant of therapeutic decisions.
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