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The natural history of unheralded complex coronary plaques
M R Chester1, L Chen, J C Kaski
1Department of Cardiological Sciences, St. George's Hospital Medical School, London, England, United Kingdom.
Insights
Unheralded complex coronary lesions, common in stable angina patients, show a higher risk of progression compared to smooth lesions, even without prior acute coronary events. These findings highlight the importance of monitoring lesion morphology.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Coronary Artery Disease
Background:
- Complex coronary stenoses, often arising from plaque disruption, are linked to rapid progression after acute coronary events.
- The incidence and behavior of complex lesions that occur without symptoms (unheralded) remain largely unknown.
Purpose of the Study:
- To evaluate the behavior of unheralded complex coronary lesions in patients without a history of acute coronary ischemia.
- To determine the risk of progression in these asymptomatic complex lesions compared to smooth stenoses.
Main Methods:
- 222 patients with chronic stable angina awaiting single-vessel percutaneous transluminal coronary angioplasty were studied.
- Repeat angiography was performed before the procedure, excluding patients with prior myocardial infarction or unstable angina.
- Quantitative and qualitative angiographic analysis was used, with categoric change defined by +/- 15% stenosis severity or total occlusion.
Main Results:
- At initial angiography, 23% of target lesions were unheralded complex (n=52), and 77% were smooth (n=170).
- Complex lesions showed a significantly higher rate of progression (14%) compared to smooth lesions (4%, p < 0.02).
- Complex stenoses were 4.2 times more likely to progress than smooth stenoses, with clinical events occurring in seven patients.
Conclusions:
- Morphologically complex coronary stenoses can develop asymptomatically and are relatively common in patients awaiting angioplasty.
- These unheralded complex lesions carry a higher risk of progression, similar to their symptomatic counterparts.
- Findings underscore the need for careful assessment and monitoring of lesion morphology in coronary artery disease management.
Objectives:
This study sought to assess the behavior of unheralded complex lesions in patients with no previous history of acute coronary ischemia.
Background:
Angiographically complex coronary stenoses appear to originate from plaque disruption and are associated with rapid progression early and late after acute coronary events. Complex lesions may occur without symptoms, but neither the incidence nor the behavior of these unheralded complex lesions is known.
Methods:
We studied 222 patients with chronic stable angina who were on a waiting list for single-vessel percutaneous transluminal coronary angioplasty of an unoccluded lesion and underwent repeat angiography immediately before the procedure as part of routine practice or shortly after a coronary event. Patients with a previous episode of myocardial infarction or unstable angina were not included. Angiograms were analyzed quantitatively and qualitatively using established methods. A change of +/- 15% stenosis severity or total coronary occlusion defined categoric change.
Results:
At first angiography, there were 52 unheralded complex target lesions (23%) and 170 smooth target stenoses (77%). Stenosis severity did not differ between complex and smooth target lesions at first and second angiography at a mean (+/- SD) interval of 7 +/- 4 months. At follow-up, seven complex lesions had progressed (14%) compared with six smooth lesions (4%, p < 0.02). Total occlusion developed in four complex lesions and one smooth lesion. Overall, complex stenoses progressed by 3 +/- 13% compared with 0.5 +/- 7% in the smooth stenoses (p = 0.15). Complex stenoses were 4.2 times more likely to progress than smooth stenoses (95% confidence interval 1.2 to 15.2 [Cornfields method]). Clinical events developed in seven patients. One complex lesion regressed and became smooth, and three smooth stenoses became complex at follow-up.
Conclusions:
Morphologically complex stenosis can develop without an episode of acute coronary ischemia and are relatively common in patients awaiting single-vessel angioplasty. Our study demonstrates that like their clinically heralded counterparts, these unheralded complex stenoses are at higher risk of progression than smooth stenoses.