Coronary Angiography, Too Far to be a Gold Standard Technique for Identifying a Vulnerable Plaque

Abstract

A 79 year-old woman with symptomatic heart failure and severe aortic stenosis was referred to a routine diagnostic coronary angiography previous to surgical aortic valve replacement. Coronary angiography showed severe stenosis in the left circumflex artery and in the ostium of the posterior descending artery. Four days later the patient presented an inferior ST-segment elevation acute coronary syndrome with cardiogenic shock. A rescue angioplasty was performed after failed thrombolysis. Coronary angiography revealed no changes in left coronary artery and a total acute occlusion in the middle segment of the right coronary artery, where only a mild lesion was observed four days before. A rescue angioplasty with a bare-metal stent implantation was performed with an optimal angiographic result. This case highlights the low ability of the conventional x-ray coronary angiography to identify vulnerable plaques. Even knowing the coronary anatomy four days before, we were unable to predict the culprit lesion.