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As clinicians, we treat symptomatic patients with coronary artery disease manifesting as either angina, anginal-like discomfort, or exertional dyspnoea. In some of these patients, symptoms progress rapidly either to rest pain and unstable angina or myocardial infarction, or to sudden death from malignant arrhythmias. However, not all patients who present with these acute coronary syndromes necessarily have a history of symptoms. In fact, in some studies the majority of such patients was asymptomatic before the acute syndrome. The acute progression of a “silent” atherosclerotic plaque to complete or nearly complete occlusion is a common substrate for an acute presentation of coronary artery disease in patients with and without prior symptoms. This editorial discusses the fact that progression to the acute presentation of coronary disease is not proportionately related to the prior severity of the coronary stenosis.
Acute coronary syndromes as secondary or primary presentations of coronary artery disease
Symptomatic patients with known coronary disease often die from myocardial infarction or die suddenly because of the acute progression of a lesion to coronary occlusion. Unfortunately, the mere fact that symptoms were present tells us little about the subsequent acute event as symptoms are not necessarily related to the plaque that progressed and was responsible for the acute event.1-3 Even the presence of ischaemia on non-invasive testing may not help in risk stratification for future acute coronary events. On follow up of a stable group of patients with a positive exercise stress test or evidence of ischaemia on ambulatory monitoring, Mulcahay et al reported that ischaemia could not predict the future occurrence of an acute coronary syndrome.4
If we presume that progression to …