Evolving concepts of the vulnerable atherosclerotic plaque and the vulnerable patient: implications for patient care and future research

Understanding the natural history of coronary artery atherosclerosis is necessary to determine prognosis and prescribe effective therapies. Traditional management of coronary artery disease has focused on the treatment of flow-limiting anatomical obstructions that lead to ischaemia. In most scenario...

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Published in:Nature reviews cardiology Vol. 20; no. 3; pp. 181 - 196
Main Authors: Gaba, Prakriti, Gersh, Bernard J, Muller, James, Narula, Jagat, Stone, Gregg W
Format: Journal Article
Language:English
Published: England Nature Publishing Group 01.03.2023
Subjects:
Acute coronary syndromes
Angina pectoris
Atherosclerosis
Cardiovascular disease
Coronary Artery Disease - diagnosis
Coronary Artery Disease - therapy
Coronary vessels
Diabetes
Heart attacks
Humans
Inflammation
Ischemia
Medical imaging
Medicine
Myocardial Infarction
Patient Care
Patients
Plaque, Atherosclerotic
Stents
Surgery
Thrombosis
Vein & artery diseases
ISSN:1759-5002, 1759-5010, 1759-5010
Online Access:Get full text
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Summary:Understanding the natural history of coronary artery atherosclerosis is necessary to determine prognosis and prescribe effective therapies. Traditional management of coronary artery disease has focused on the treatment of flow-limiting anatomical obstructions that lead to ischaemia. In most scenarios, revascularization of these atherosclerotic plaques has not substantially improved freedom from death or myocardial infarction, questioning the utility of contemporary revascularization strategies to improve prognosis. Advances in non-invasive and invasive imaging techniques have helped to identify the characteristics of obstructive and non-obstructive plaques that are precursors for plaque progression and future acute coronary syndromes as well as cardiac death. These 'vulnerable plaques' develop as a consequence of systemic inflammation and are prone to inducing thrombosis. Vulnerable plaques most commonly have a large plaque burden with a well-formed necrotic core and thin fibrous cap and are metabolically active. Perivascular adipose tissue might, in some patients, be used as a surrogate for coronary inflammation and predict future risk of adverse cardiac events. Vulnerable plaques can be identified in their quiescent state, offering the potential for therapeutic passivation. In this Review, we describe the biological and compositional features of vulnerable plaques, the non-invasive and invasive diagnostic modalities to characterize vulnerable plaques, the prognostic utility of identifying vulnerable plaques, and the future studies needed to explore the value of intensified pharmacological and focal treatments of vulnerable plaques.
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ISSN:1759-5002
1759-5010
1759-5010
DOI:10.1038/s41569-022-00769-8