A prospective natural-history study of coronary atherosclerosis.
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 mm(2) 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.).
Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY 10022, USA. gs2184@columbia.edu
Gregg W
GW
Stone
Akiko
A
Maehara
Alexandra J
AJ
Lansky
Bernard
B
de Bruyne
Ecaterina
E
Cristea
Gary S
GS
Mintz
Roxana
R
Mehran
John
J
McPherson
Naim
N
Farhat
Steven P
SP
Marso
Helen
H
Parise
Barry
B
Templin
Roseann
R
White
Zhen
Z
Zhang
Patrick W
PW
Serruys
D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy; D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D017023:Coronary Angiography / Q000379:methods; D003324:Coronary Artery Disease / Q000150:complications* / Q000000981:diagnostic imaging / Q000473:pathology; D003331:Coronary Vessels / Q000473:pathology*; D018450:Disease Progression; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012008:Recurrence; D012307:Risk Factors; D018084:Ultrasonography, Interventional / Q000379:methods