A new look at coronary angiograms: plaque morphology as a help to diagnosis and to evaluate outcome.

Characterization of plaque morphology can provide useful information beyond those generally yielded by the more traditional methods of interpretation of coronary angiograms based on assessment of severity of stenoses and number of diseased vessels. Focus on the culprit coronary lesion in acute myocardial infarction and in unstable angina allows recognition of the complex plaque and of presence of endoluminal thrombi that are closely associated to the mechanisms of the disease. Response to treatment in these clinical situations, and the healing process can be assessed by repeated opacifications of the lesion. The presence of a residual thrombus is associated with a worse clinical outcome and also a higher risk of complication if coronary angioplasty is performed. The prognostic information derived from the morphologic analysis extends to the chronic phase of the disease. The extent score of disease, defined as the sum of coronary artery segments showing a narrowing of any severity marks more severe disease and predicts future progression. Severity of stenosis is also a predictor. More severe lesions will occlude more frequently but most often without clinical consequences. Occlusion of less severe stenosis, on the other hand, leads to acute myocardial infarction or to the other manifestations of acute coronary syndromes. Other morphologic features are also associated with a higher risk of myocardial infarction. These include a geometry favoring blood flow separation and turbulence such as acute inflow and outflow angles of the stenosis and presence of a division within its vicinity. This new look at coronary angiograms may help orient therapy. Patients with angina and a significant stenosis will profit from a corrective intervention. Others with a high extent score should receive a comprehensive program for control of risk factors. Patients with a lesion of borderline significance at risk of activation should be closely monitored, and when clinical symptoms evolve, receive more intensive antithrombotic therapy. Quantification of the morphologic characteristics of the plaque, coupled to new techniques for endovascular imaging should lead in the future to better diagnostic and better risk stratification.