State-of-the-Art Review
Physiological Predictors of Acute Coronary Syndromes: Emerging Insights From the Plaque to the Vulnerable Patient

https://doi.org/10.1016/j.jcin.2017.08.059Get rights and content
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Abstract

In this review, the authors explore the evolving evidence linking physiological assessment of coronary artery disease with plaque progression and vulnerability. Reducing adverse clinical events remains the ultimate goal for diagnostic tests, and this review highlights evidence supporting the prognostic value of physiological metrics in predicting outcomes. Historical and contemporary studies support synergy among lesion severity, ischemia, plaque vulnerability, and patient prognosis. Ischemia contributes to clinical events through association with plaque burden, but this review addresses the emerging concept that it associates with atherothrombosis via disturbed lesion hemodynamics. Biomechanical pathophysiological forces including endothelial shear stress—the frictional force generated by blood flow on the vessel wall—are increasingly linked with atherogenesis, vulnerable plaque morphology, and platelet and leukocyte activation. The authors conclude by transitioning from the model of the vulnerable plaque to the concept of the “vulnerable patient,” looking more broadly at physiological contributors to Virchow’s triad underpinning acute coronary syndrome.

Key Words

acute coronary syndromes(s)
coronary physiology
endothelial shear stress
mechanisms of atherosclerosis
plaque vulnerability

Abbreviations and Acronyms

ACS
acute coronary syndrome(s)
CTA
computed tomographic angiography
DS
diameter stenosis
ESS
endothelial shear stress
FFR
fractional flow reserve
MACE
major adverse cardiac event(s)
MI
myocardial infarction
PCI
percutaneous coronary intervention
SPECT
single-photon emission computed tomography
TCFA
thin-cap fibroatheroma

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Drs. Ford and Berry have received research support from the British Heart Foundation (grant RE-13-5-30177). The authors have reported that they have no relationships relevant to the contents of this paper to disclose.