Testing the Efficacy of Lipid-Lowering Therapy Versus Revascularization: The Time Has Come, or Is It Past Due?

Abstract

To the Editor: Small, lipid-rich, vulnerable plaques that are angiographically unimpressive and hemodynamically insignificant are responsible for most cases of fatal and nonfatal myocardial infarctions, whereas large, stable plaques that produce angiographically severe stenoses generally result in stable angina but rarely result in myocardial infarction. Accordingly, lipid-optimizing therapy, which stabilizes the vulnerable plaques, may have a major impact on prevention of myocardial infarction and death, whereas revascularization procedures, which are directed at severely stenotic lesions, may not. Therefore, I was particularly struck by the fascinating conclusion by Forrester and Shah1 in Circulation : “Coronary angiography does not identify, and consequently revascularization therapies do not treat, the lesions that lead to myocardial infarction.” Their conclusions, if proven correct, will have enormous implications for the management of coronary artery disease, since coronary angiography has been the gold standard for its diagnosis and revascularization its mainstay of treatment for decades. The United States is home to only 5% of the world’s population but performs almost 50% of the invasive coronary procedures worldwide. Of a total of 900 000 coronary angioplasties performed worldwide in 1994, 404 000 were done in the United States, at an average cost of $21 700 each.2 Another 501 000 coronary bypass surgeries and 1.1 million coronary angiograms were done on Americans the same year, each at an average cost of $44 200 and $10 880, respectively. Revascularization procedures are done in 58% of all acute myocardial infarctions and account for about half the cost of hospital admission for this condition.3 Ironically, …