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The elusive link between stenosis severity and prognosis in stable ischaemic heart disease
  1. F Crea,
  2. G A Lanza
  1. Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Roma, Italy
  1. Correspondence to:
    Professor Filippo Crea, Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 – Roma, Italy;

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When assessing patients with stable ischaemic heart disease, cardiologists should not just take into account the number of critical stenoses detected at angiography, but should also consider patient symptoms, left ventricular function, the extent of myocardium at risk of ischaemia, and the extent of coronary atherosclerosis

It is well recognised that the number of coronary artery branches with a “critical stenosis” at angiography is a predictor of future cardiac events.1 Accordingly, the major scope of invasive cardiology is the identification and subsequent treatment of critical stenoses.

Yet a large body of evidence challenges the notion that critical stenoses are the most frequent site of future subtotal or total occlusions resulting in acute coronary syndromes. Indeed, serial angiographic studies have consistently shown that in about 85% of patients, coronary occlusion resulting in acute myocardial infarction occurs at the site of non-critical stenoses.2 Furthermore, severe stenoses often remain unchanged over time, whereas new critical obstructions may develop, even after a short follow up, in segments which had previously been found normal or near normal at angiography.3,4 Accordingly, cross-sectional angiographic studies have shown that patients who present with stable angina as the first manifestation of ischaemic heart disease (IHD), compared to patients who present with an acute coronary syndrome, exhibit more severe coronary atherosclerosis, including a higher number of total coronary occlusions.5 Finally, it should be noted that even when total coronary occlusion occurs …

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