(Circulation. 1995;92:2333-2342.)
© 1995 American Heart Association, Inc.
Articles |
Our Preoccupation With Coronary Luminology
The Dissociation Between Clinical and Angiographic Findings in Ischemic Heart Disease
From the Department of Cardiology and the Joseph J. Jacobs Center for Thrombosis and Vascular Biology, Cleveland Clinic Foundation, Cleveland, Ohio.
Correspondence to Eric J. Topol, MD, Department of Cardiology, Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F25, Cleveland, Ohio 44195. E-mail internettopole@ccsmtp.ccf.org.
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.
Key Words: angiography • myocardial infarction • atherosclerosis • revascularization • angioplasty
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M. Ruscazio, R. Montisci, and S. Iliceto Expanding the noninvasive coronary physiology assessment with transthoracic Doppler echocardiography Eur J Echocardiogr, September 1, 2003; 4(3): 159 - 161. [Full Text] [PDF]
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K.-H. Mak and D. P. Faxon Clinical studies on coronary revascularization in patients with type 2 diabetes Eur. Heart J., June 2, 2003; 24(12): 1087 - 1103. [Abstract] [Full Text] [PDF]
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M. A. Leesar, T. Abdul-Baki, N. I. Akkus, A. Sharma, T. Kannan, and R. Bolli Use of fractional flow reserve versus stress perfusion scintigraphy after unstable angina: Effect on duration of hospitalization, cost, procedural characteristics, and clinical outcome J. Am. Coll. Cardiol., April 2, 2003; 41(7): 1115 - 1121. [Abstract] [Full Text] [PDF]
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R. G. McKay "Ischemia-guided" versus "early invasive" strategies in the management of acute coronary syndrome/non-ST-segment elevation myocardial infarction: The interventionalist's perspective J. Am. Coll. Cardiol., February 19, 2003; 41(4_Suppl_S): 96S - 102S. [Abstract] [Full Text] [PDF]
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S. E. Nissen Pathobiology, not angiography, should guide managementin acute coronary syndrome/non-ST-segment elevation myocardial infarction: The non-interventionist's perspective J. Am. Coll. Cardiol., February 19, 2003; 41(4_Suppl_S): 103S - 112S. [Abstract] [Full Text] [PDF]
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D. E. Cutlip, M. S. Chauhan, D. S. Baim, K. K. L. Ho, J. J. Popma, J. P. Carrozza, D. J. Cohen, and R. E. Kuntz Clinical restenosis after coronary stenting: perspectives from multicenter clinical trials J. Am. Coll. Cardiol., December 18, 2002; 40(12): 2082 - 2089. [Abstract] [Full Text] [PDF]
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D. Brosh, S. T. Higano, M. J. Slepian, H. I. Miller, M. J. Kern, R. J. Lennon, D. R. Holmes Jr, and A. Lerman Pulse transmission coefficient: a novel nonhyperemic parameter for assessing the physiological significance of coronary artery stenoses J. Am. Coll. Cardiol., March 20, 2002; 39(6): 1012 - 1019. [Abstract] [Full Text] [PDF]
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S. A. J. Chamuleau, R. A. Tio, C. C. de Cock, E. D. de Muinck, N. H. J. Pijls, B. L. F. van Eck-Smit, K. T. Koch, M. Meuwissen, M. G. W. Dijkgraaf, A. de Jong, et al. Prognostic value of coronary blood flow velocity and myocardial perfusion in intermediate coronary narrowings and multivessel disease J. Am. Coll. Cardiol., March 6, 2002; 39(5): 852 - 858. [Abstract] [Full Text] [PDF]
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C.L. de Korte, S.G. Carlier, F. Mastik, M.M. Doyley, A.F.W. van der Steen, P.W. Serruys, and N. Bom Morphological and mechanical information of coronary arteries obtained with intravascular elastography. Feasibility study in vivo Eur. Heart J., March 1, 2002; 23(5): 405 - 413. [Abstract] [Full Text] [PDF]
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F Chirillo, A Bruni, G Balestra, C Cavallini, Z Olivari, J D Thomas, and P Stritoni Assessment of internal mammary artery and saphenous vein graft patency and flow reserve using transthoracic Doppler echocardiography Heart, October 1, 2001; 86(4): 424 - 431. [Abstract] [Full Text] [PDF]
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H. Mudra, C. di Mario, P. de Jaegere, H. R. Figulla, C. Macaya, R. Zahn, B. Wennerblom, W. Rutsch, V. Voudris, E. Regar, et al. Randomized Comparison of Coronary Stent Implantation Under Ultrasound or Angiographic Guidance to Reduce Stent Restenosis (OPTICUS Study) Circulation, September 18, 2001; 104(12): 1343 - 1349. [Abstract] [Full Text] [PDF]
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D. J. Cohen, M. Doucet, D. E. Cutlip, K. K.L. Ho, J. J. Popma, and R. E. Kuntz Impact of Smoking on Clinical and Angiographic Restenosis After Percutaneous Coronary Intervention: Another Smoker's Paradox? Circulation, August 14, 2001; 104(7): 773 - 778. [Abstract] [Full Text] [PDF]
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P. C. Keelan, L. F. Bielak, K. Ashai, L. S. Jamjoum, A. E. Denktas, J. A. Rumberger, P. F. Sheedy, II, P. A. Peyser, and R. S. Schwartz Long-Term Prognostic Value of Coronary Calcification Detected by Electron-Beam Computed Tomography in Patients Undergoing Coronary Angiography Circulation, July 24, 2001; 104(4): 412 - 417. [Abstract] [Full Text] [PDF]
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C. R. deFilippi, S. Rosanio, M. Tocchi, R. J. Parmar, M. A. Potter, B. F. Uretsky, and M. S. Runge Randomized comparison of a strategy of predischarge coronary angiography versus exercise testing in low-risk patients in a chest pain unit: in-hospital and long-term outcomes J. Am. Coll. Cardiol., June 15, 2001; 37(8): 2042 - 2049. [Abstract] [Full Text] [PDF]
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