Author + information
- Received March 3, 2019
- Revision received July 30, 2019
- Accepted August 1, 2019
- Published online September 16, 2019.
- Amir Ahmadi, MDa,b,
- Edgar Argulian, MDa,
- Jonathon Leipsic, MDb,
- David E. Newby, MDc and
- Jagat Narula, MD, PhDa,∗ ()
- aIcahn School of Medicine at Mount Sinai Hospital, New York, New York
- bSt. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
- cBritish Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
- ↵∗Address for correspondence:
Dr. Jagat Narula, Mount Sinai Heart, One Gustave L. Levy Place; Box 1030, New York, New York 10029.
• The majority of coronary artery events occur as a result of plaque rupture.
• Plaque progression is a necessary but modifiable step between subclinical atherosclerosis and plaque rupture.
• Subclinical atherosclerosis can be conveniently detected with noninvasive imaging.
• Intensive lipid-lowering therapy can halt plaque progression and should reduce events.
It has been believed that most acute coronary events result from the rupture of mildly stenotic plaques, based on studies in which angiographic information was available from many months to years before the event. However, serial studies in which angiographic data were available from the past as also within 1 to 3 months of myocardial infarction have clarified that nonobstructive lesions progressively enlarged relatively rapidly before the acute event occurred. Noninvasive computed tomography angiography imaging data have confirmed that lesions that did not progress voluminously over time rarely led to events, regardless of the extent of luminal stenosis or baseline high-risk plaque morphology. Therefore, plaque progression could be proposed as a necessary step between early, uncomplicated atherosclerosis and plaque rupture. On the other hand, it has been convincingly demonstrated that intensive lipid-lowering therapy (to a low-density lipoprotein cholesterol level of <70 mg/dl) halts plaque progression. Given the current ability to noninvasively detect the presence of early atherosclerosis, the importance of plaque progression in the pathogenesis of myocardial infarction, and the efficacy of maximum lipid-lowering therapy, it has been suggested that plaque progression is a modifiable step in the evolution of atherosclerotic plaque. A personalized approach based on the detection of early atherosclerosis can trigger the necessary treatment to prevent plaque progression and hence plaque instability. Therefore, this approach can redefine the traditional paradigm of primary and secondary prevention based on population-derived risk estimates and can potentially improve long-term outcomes.
- acute coronary syndrome
- cardiovascular health
- CT angiography
- primary prevention
- secondary prevention
- statin therapy
Dr. Leipsic has served as a consultant for and holds stock options in Circle CVI and HeartFlow; and has received research support from GE Healthcare. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Stephan Achenbach, MD, served as Guest Associate Editor for this paper.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received March 3, 2019.
- Revision received July 30, 2019.
- Accepted August 1, 2019.
This article requires a subscription or purchase to view the full text. If you are a subscriber or member, click Login or the Subscribe link (top menu above) to access this article.