Dr. Weeks’ Comment: This is why we recommend, for appropriate patients, the actual coronary screening tests like calcium scores. (we also offer blood tests like fibrinogen, cardiac specific C- reactive protein, lipoprotein (a) and homocysteine – the relevant cardiac screening tests!)
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A Prospective Natural-History Study of Coronary Atherosclerosis
Gregg W. Stone, M.D., Akiko Maehara, M.D., Alexandra J. Lansky, M.D., Bernard de Bruyne, M.D., Ecaterina Cristea, M.D., Gary S. Mintz, M.D., Roxana Mehran, M.D., John McPherson, M.D., Naim Farhat, M.D., Steven P. Marso, M.D., Helen Parise, Sc.D., Barry Templin, M.B.A., Roseann White, M.A., Zhen Zhang, Ph.D., and Patrick W. Serruys, M.D., Ph.D. for the PROSPECT Investigators
N Engl J Med 2011; 364:226-235January 20, 2011
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Background
Atherosclerotic plaques that lead to acute coronary syndromes often occur at sites of angiographically mild coronary-artery stenosis. Lesion-related risk factors for such events are poorly understood.
Methods
In a prospective study, 697 patients with acute coronary syndromes underwent three-vessel coronary angiography and gray-scale and radiofrequency intravascular ultrasonographic imaging after percutaneous coronary intervention. Subsequent major adverse cardiovascular events (death from cardiac causes, cardiac arrest, myocardial infarction, or rehospitalization due to unstable or progressive angina) were adjudicated to be related to either originally treated (culprit) lesions or untreated (nonculprit) lesions. The median follow-up period was 3.4 years.
Results
The 3-year cumulative rate of major adverse cardiovascular events was 20.4%. Events were adjudicated to be related to culprit lesions in 12.9% of patients and to nonculprit lesions in 11.6%. Most nonculprit lesions responsible for follow-up events were angiographically mild at baseline (mean [±SD] diameter stenosis, 32.3±20.6%). However, on multivariate analysis, nonculprit lesions associated with recurrent events were more likely than those not associated with recurrent events to be characterized by a plaque burden of 70% or greater (hazard ratio, 5.03; 95% confidence interval [CI], 2.51 to 10.11; P<0.001) or a minimal luminal area of 4.0 mm2 or less (hazard ratio, 3.21; 95% CI, 1.61 to 6.42; P=0.001) or to be classified on the basis of radiofrequency intravascular ultrasonography as thin-cap fibroatheromas (hazard ratio, 3.35; 95% CI, 1.77 to 6.36; P<0.001).
Conclusions
In patients who presented with an acute coronary syndrome and underwent percutaneous coronary intervention, major adverse cardiovascular events occurring during follow-up were equally attributable to recurrence at the site of culprit lesions and to nonculprit lesions. Although nonculprit lesions that were responsible for unanticipated events were frequently angiographically mild, most were thin-cap fibroatheromas or were characterized by a large plaque burden, a small luminal area, or some combination of these characteristics, as determined by gray-scale and radiofrequency intravascular ultrasonography. (Funded by Abbott Vascular and Volcano; ClinicalTrials.gov number, NCT00180466.)