Our Preoccupation With Coronary Luminology

Abstract

Nearly 40 years after its invention, the angiogram is still considered by most physicians to be the "gold standard" for defining coronary anatomy. Careful investigations have revealed many deficiencies inherent in this approach. The purpose of this article is to outline the evidence that our current preoccupation with coronary "luminology" may be misguided and to propose a rational paradigm for future practice and investigation. Angiography depicts coronary anatomy from a planar two-dimensional silhouette of the lumen. Angiography is limited in resolution to four or five line pairs per millimeter. Confounding factors include vessel tortuosity, overlap of structures, and the effects of lumen shape. After intervention, a hazy, broadened silhouette may overestimate the actual gain in lumen size. Studies show marked disparity between the apparent severity of lesions and their physiological effects. After myocardial infarction, cardiologists too often do not make an attempt to demonstrate the physiological significance of the stenosis before performing percutaneous coronary revascularization. Similarly, the allure of a better, more gratifying angiogram with new interventional devices appears to be a dominant factor in their popularity. Interventional cardiologists should be aware that techniques yielding marked angiographic benefit may also generate important but unrecognized hazards. The dissociation between the angiogram and clinical outcome should influence future research efforts. Our review of the literature indicates that we may benefit from shifting the current focus and preoccupation with coronary luminology to achieving the desired clinical end point: promoting survival and long-term freedom from myocardial infarction and the disabling symptoms of coronary heart disease.

Significance of Microvascular Function in Visual—Functional Mismatch Between Invasive Coronary Angiography and Fractional Flow Reserve

“…This cut‐off value has been used for the threshold of inducible ischemia; therefore, it is accepted as the gold standard for guiding revascularization, validating noninvasive testing, and evaluating outcomes after revascularization strategies 2, 3, 4. However, cumulative evidence suggests that angiographically determined anatomical stenosis severity often underestimates or overestimates the functional significance of lesions 5, 6, 7. Fractional flow reserve (FFR) is currently the standard for decision‐making regarding revascularization in the catheter laboratory and has become part of the clinical guidelines for the assessment of the physiological significance of epicardial coronary stenosis based on sound concepts and randomized clinical trials 8, 9, 10, 11.…”

Cardiac hybrid imaging: state-of-the-art

“…This is further underlined by the fact that invasive coronary angiography is very poorly correlated with postmortem coronary anatomy (5,6). Most importantly, angiographic findings are poor predictors of physiologic relevance of a coronary stenosis (4,(7)(8)(9)(10). A substantial fraction -namely between 20% and 40% -of all diagnostic invasive coronary angiograms reveal clinically insignificant disease (1).…”

LDL-cholesterol lowering and atherosclerosis - clinical benefit and possible mechanisms: an update

“…Moreover, enhanced vasoconstriction potentially promotes plaque Assur ing and ulceration, which may lead to thrombosis [96,97]. Evidently, there seems to be a dissociation between the results of angiographic studies and clini cal outcome: lipid-lowering therapy has been shown to reduce the incidence of cardiovascular events with only small changes in coronary anatomy [98,99]. Therefore, it is most likely that treatment of hypercholesterolaemia depletes the lipid core of early atheromatous plaques, and consequently stabilizes these lipid-rich lesions and prevents further compli cations such as intramural haemorrhage and intralu minal thrombosis, an assumption that has been demonstrated in the Canadian Coronary Atheroscle rosis Intervention Trial (CCAIT) and the Stanford Coronary Risk Intervention Project (SCRIP) [28,100].…”