Document Detail

Pathobiology, not angiography, should guide management in acute coronary syndrome/non-ST-segment elevation myocardial infarction: the non-interventionist's perspective.
MedLine Citation:
PMID:  12644348     Owner:  NLM     Status:  MEDLINE    
Although an early invasive strategy (angiography and percutaneous coronary intervention) is the convention in acute coronary syndrome (ACS)/non-ST-segment elevation myocardial infarction (MI) in the U.S., a conservative pharmacologic approach is common in other countries. Trial evidence has demonstrated a modest benefit with an angiographically guided approach; but patients having negative troponin values or who were receiving aspirin showed little or no benefit, and those without ST-segment changes had slightly worse outcomes. Limitations of angiography are clinically important. Identification of hemodynamically significant stenoses may be confounded by coronary remodeling. Also, most plaques, particularly those responsible for acute events, are extraluminal. Assessment of the luminal diameter of a lesion, which requires comparison with a normal reference segment, may be impossible because of the diffuse nature of the disease. Percutaneous coronary intervention after plaque rupture may itself cause embolization and no-reflow phenomena, leading to severe complications. In addition, most ruptures may be clinically silent. Evidence of a systemic inflammatory component suggests that ACS patients are at risk for plaque rupture at multiple sites. The inability of angiography to depict the true extent of atherosclerosis is supported by necropsy and transplant donor studies. A metabolic approach to this systemic disease is the only strategy designed to influence the behavior of both the small number of angiographically visible lesions and the large number of occult plaques. Statins and other agents decrease the incidence of death and MI by stabilizing atherosclerotic plaques throughout the coronary bed, reducing inflammation, collagen degradation, tissue factor expression, and vasomotor tone.
Steven E Nissen
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Publication Detail:
Type:  Journal Article; Review    
Journal Detail:
Title:  Journal of the American College of Cardiology     Volume:  41     ISSN:  0735-1097     ISO Abbreviation:  J. Am. Coll. Cardiol.     Publication Date:  2003 Feb 
Date Detail:
Created Date:  2003-03-19     Completed Date:  2003-06-19     Revised Date:  2007-11-15    
Medline Journal Info:
Nlm Unique ID:  8301365     Medline TA:  J Am Coll Cardiol     Country:  United States    
Other Details:
Languages:  eng     Pagination:  103S-112S     Citation Subset:  AIM; IM    
Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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MeSH Terms
Acute Disease
Angina, Unstable / diagnosis*,  therapy*
Angioplasty, Transluminal, Percutaneous Coronary
Coronary Angiography
Coronary Artery Disease / pathology,  radiography
Disease Progression
Heptanoic Acids / therapeutic use
Hydroxymethylglutaryl-CoA Reductase Inhibitors / therapeutic use
Myocardial Infarction / diagnosis*,  therapy*
Outcome Assessment (Health Care)
Pyrroles / therapeutic use
Randomized Controlled Trials as Topic
Reg. No./Substance:
0/Heptanoic Acids; 0/Hydroxymethylglutaryl-CoA Reductase Inhibitors; 0/Pyrroles; 110862-48-1/atorvastatin

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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