Improving outcomes in symptomatic obstructive coronary artery disease From intervention to tailored prevention

Symptomatic obstructive coronary artery disease is still assessed one stenosis at a time. This thesis argues for a more holistic approach, in which the interrogation of an individual lesion, the phenotyping of the atherosclerotic burden that surrounds it, the risk factors that drive the underlying disease in an individual patient, and the tailoring of secondary prevention are treated as one continuum rather than as four sequential decisions.
The flow-limiting capacity of a coronary lesion forecasts symptom persistence and adverse events and thereby guides treatment decisions. Such capacity is most often interrogated with the use of wire-based pressure assessment; these measurements are, however, infrequently performed, and angiography-derived indices provide a clinically usable tool with which this underuse may be targeted. Image-based interrogation yields more than flow limitation alone, as such metrics also reveal risk features of disease. Yet patterns of discordance between angiography-derived metrics and well-calibrated wire-based assessment must be recognized for accuracy. Periprocedural intravascular imaging may further characterize plaques identified as high-risk at the time of intervention.Complete risk assessment complements this physiological interrogation. Distinct disease and risk phenotypes become apparent on invasive angiography and on non-invasive imaging; patients with elevated lipoprotein(a) exhibit more diffuse and extensive disease as demonstrated in this thesis, and such a phenotype identifies them as candidates for intensified rather than standard secondary prevention.
In summary, the assessment made in the catheterization laboratory serves prevention as much as it serves the procedure, and the emphasis shifts from treating a stenosis to halting the atherosclerotic process that produced it.