Abstract
The concept of the 'vulnerable plaque' originated from pathological observations in patients who died from acute coronary syndrome. This recognition spawned a generation of research that led to greater understanding of how complicated atherosclerotic plaques form and precipitate thrombotic events. In current practice, an increasing number of patients who survive their first event present with non-ST-segment elevation myocardial infarction (NSTEMI) rather than myocardial infarction (MI) with ST-segment elevation (STEMI). The culprit lesions that provide the pathological substrate for NSTEMI can vary considerably from the so-called 'vulnerable plaque'. The shift in clinical presentation of MI and stroke corresponds temporally to a progressive change in the characteristics of human plaques away from the supposed characteristics of vulnerability. These alterations in the structure and function of human atherosclerotic lesions might mirror the modifications that are produced in experimental plaques by lipid lowering, inspired by the vulnerable plaque construct. The shift in the clinical presentations of the acute coronary syndromes mandates a critical reassessment of the underlying mechanisms, proposed risk scores, the results and interpretation of preclinical experiments, as well as recognition of the limitations of the use of population data and samples collected before the application of current preventive interventions.
Highlights
Temporal changes in the clinical presentation of cardiovascular patients Since the 1980s the development and increasingly widespread application of effective pharmacologic lipid-lowering and antihypertensive agents and of percutaneous interventions, along with risk factor management have made inroads curbing the worldwide epidemic of cardiovascular disease
The shift in the clinical presentations of the acute coronary syndromes mandates a critical reassessment of the underlying mechanisms, proposed risk scores, the results and interpretation of pre-clinical experiments, as well as recognition of the limitations of the use of population data and samples harvested before the application of current preventive interventions
The improved understanding and treatment of classical risk factors for atherosclerosis, has occurred in the face of a countervailing worldwide increase in obesity and dysmetabolism that may drive the wave of epidemic cardiovascular disease
Summary
An increasing number of patients presenting with myocardial infarction (MI) are diagnosed with a non ST-elevated myocardial infarction (NSTEMI) rather than a MI with ST-elevation (STEMI) and survive their first event. The shift in the clinical presentations of the acute coronary syndromes mandates a critical reassessment of the underlying mechanisms and the concept of the vulnerable plaque. The change in clinical presentation and warrant critical re-assessment of currently applied cardiovascular risk scores, pre-clinical experiments, and the usefulness of population data and samples harvested before the application of current preventive interventions The shift in the clinical presentations of the acute coronary syndromes mandates a critical reassessment of the underlying mechanisms and the concept of the vulnerable plaque. The change in clinical presentation and warrant critical re-assessment of currently applied cardiovascular risk scores, pre-clinical experiments, and the usefulness of population data and samples harvested before the application of current preventive interventions
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