The Plaque Hypothesis: a review
Major adverse cardiac events have been found to be associated not just with coronary obstructive lesions; this was the previous hypothesis, entitled the ischemia hypothesis or the stenosis hypothesis. It is now understood that the plaque burden along the entire coronary tree may affect major adverse cardiac events. This was found because traditionally, severely obstructive focal plaque regions were targeted for revascularization, however such targeting did not always correlate with major adverse cardiac events. Furthermore, treating obstructive epicardial flow-limiting stenoses alone does not reduce the risk of major adverse cardiac events in patients with chronic coronary artery disease. Now, factors such as lipid accumulation, thin cap fibroatheroma morphology and large plaque burden are explored, which are associated with increased chances of major adverse cardiac events. The location and properties of a plaque can vary hugely among individuals, leading to varied plaque destabilisation, and therefore occurrence of major adverse cardiac events.
This review by Stone PH et al. aimed to explore how the plaque hypothesis may be used to inform treatment and management strategies for patients with plaque anywhere in their coronary arteries.
It is vital to focus on the whole of the coronary artery and its plaques to effectively aid in reducing major adverse cardiac events. To do this, assessing multiple factors such as the biochemical, anatomic and biomechanical characteristics of plaques can be useful. Features such as low-attenuation plaque, spotty calcification, napkin-ring sign and axial plaque stress should be assessed, as these features hold a high ability to prediction major adverse cardiac events.