The coronary substrate determines prognosis in acute coronary syndromes: the kaleidoscope has been shaken … again!

Abstract

This editorial refers to ‘Plaque rupture and intact fibrous cap assessed by optical coherence tomography portend different outcomes in patients with acute coronary syndrome’[†][1], by G. Niccoli et al., on page 1377. The identification of ‘vulnerable’ or ‘high risk’ coronary plaques has represented the quest for the Holy Grail in interventional cardiology for the past three decades. Plaque rupture (PR), plaque erosion (PE), and complicated calcified nodules (CNs) constitute the most common underlying substrates leading to coronary thrombosis and acute coronary syndromes (ACS).1–3 Despite the advent of novel intracoronary imaging techniques, which are able to disclose unique morphological insights and plaque features similar to those found in plaques already complicated with coronary thrombosis, their value in predicting future clinical events remains limited.4–7 Optical coherence tomography (OCT) is an emerging technique with unique spatial resolution (15–20 μm) that provides unsurpassed visualization of the coronary surface although with limited penetration in the underlying coronary wall.4–7 This technique is ideally suited to unravel even subtle fibrous cap disruptions, intracoronary thrombus, and the underlying necrotic cores. The thickness of the fibrous cap can be accurately measured and, therefore, thin-cap fibroatheromas (TCFAs) may be readily identified.4–7 However, the implications of the discovery of the various pathological substrates on the long-term prognosis of ACS patients remain unknown. In this issue of the journal, Niccoli et al .8 sought to assess the prognostic implications of PR in ACS patients. OCT was systematically performed in patients presenting with ACS to detect the presence of PR vs. an intact fibrous cap (IFC) at the culprit lesions. The primary … [1]: #fn-2