The Myth of 'stable' Coronary Artery Disease

Overview

Journal Nat Rev Cardiol

Specialty Cardiology & Vascular Diseases

Date 2019 Jul 31

PMID 31358978

Citations 59

Authors

Keith A A Fox

Marco Metra

Joao Morais

Dan Atar

Affiliations

Soon will be listed here.

Abstract

Patients with known cardiovascular disease who have not had a recent acute event are often referred to as having stable coronary artery disease (CAD). The concept of 'stable' CAD is misleading for two important reasons: the continuing risks of cardiovascular events over the longer term and the diverse spectrum of powerful risk characteristics. The risks of cardiovascular events are frequently underestimated and continue to exist, despite current standards of care for secondary prevention, including lifestyle changes, optimal medical therapy, myocardial revascularization and the use of antiplatelet agents to limit thrombosis. In dispelling the myth of 'stable' CAD, we explore the pathophysiology of the disease and the relative contribution of plaque and systemic factors to cardiovascular events. A broader concept of the vulnerable patient, not just the vulnerable plaque, takes into account the diversity and future risks of atherothrombotic events. We also evaluate new and ongoing research into medical therapies aimed at further reducing the risks of cardiovascular events in patients with chronic - but not stable - atherothrombotic disease.

Citing Articles

PRDM16 controls smooth muscle cell fate in atherosclerosis.

Tan J, Cheng L, Calhoun R, Weller A, Drareni K, Fong S bioRxiv. 2025; .

PMID: 40027729 PMC: 11870537. DOI: 10.1101/2025.02.19.639186.

Beyond the Lumen: Molecular Imaging to Unmask Vulnerable Coronary Plaques.

Currie G, Kiat H J Cardiovasc Dev Dis. 2025; 12(2).

PMID: 39997485 PMC: 11856627. DOI: 10.3390/jcdd12020051.

Therapeutic effect and potential mechanism of Fufang Danshen dripping pills for stable coronary heart disease: a randomized controlled trial.

Meng L, Huang P, Li Q, Feng Y, Li D, Wu G Front Cardiovasc Med. 2025; 12:1506917.

PMID: 39944604 PMC: 11813928. DOI: 10.3389/fcvm.2025.1506917.

Knowledge, attitude, and practice of coronary heart disease patients towards antithrombotic therapy.

Du Y, Cai X, Hong X, Chen Y, Chen C, Gong J BMC Public Health. 2025; 25(1):549.

PMID: 39930408 PMC: 11812212. DOI: 10.1186/s12889-025-21678-8.

A review of cutting-edge biomarkers for diagnosing coronary artery disease.

Azami P, Mohammadzadeh S, Seirafi S, Razeghian-Jahromi I Medicine (Baltimore). 2025; 104(4):e41377.

PMID: 39854741 PMC: 11771658. DOI: 10.1097/MD.0000000000041377.

References

Montalescot G, Sechtem U, Andreotti F, Arden C, Budaj A, Bugiardini R . 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013; 34(38):2949-3003. DOI: 10.1093/eurheartj/eht296. View

Bonaca M, Bhatt D, Cohen M, Steg P, Storey R, Jensen E . Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med. 2015; 372(19):1791-800. DOI: 10.1056/NEJMoa1500857. View

Morrow D, Braunwald E, Bonaca M, Ameriso S, Dalby A, Fish M . Vorapaxar in the secondary prevention of atherothrombotic events. N Engl J Med. 2012; 366(15):1404-13. DOI: 10.1056/NEJMoa1200933. View

Connolly S, Eikelboom J, Bosch J, Dagenais G, Dyal L, Lanas F . Rivaroxaban with or without aspirin in patients with stable coronary artery disease: an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017; 391(10117):205-218. DOI: 10.1016/S0140-6736(17)32458-3. View

Ridker P, Everett B, Thuren T, MacFadyen J, Chang W, Ballantyne C . Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease. N Engl J Med. 2017; 377(12):1119-1131. DOI: 10.1056/NEJMoa1707914. View

Cannon C, Blazing M, Giugliano R, McCagg A, White J, Theroux P . Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes. N Engl J Med. 2015; 372(25):2387-97. DOI: 10.1056/NEJMoa1410489. View

Clayton T, Lubsen J, Pocock S, Voko Z, Kirwan B, Fox K . Risk score for predicting death, myocardial infarction, and stroke in patients with stable angina, based on a large randomised trial cohort of patients. BMJ. 2005; 331(7521):869. PMC: 1255789. DOI: 10.1136/bmj.38603.656076.63. View

Falk E, Nakano M, Bentzon J, Finn A, Virmani R . Update on acute coronary syndromes: the pathologists' view. Eur Heart J. 2012; 34(10):719-28. DOI: 10.1093/eurheartj/ehs411. View

Libby P, Theroux P . Pathophysiology of coronary artery disease. Circulation. 2005; 111(25):3481-8. DOI: 10.1161/CIRCULATIONAHA.105.537878. View

10.

Arbab-Zadeh A, Fuster V . The myth of the "vulnerable plaque": transitioning from a focus on individual lesions to atherosclerotic disease burden for coronary artery disease risk assessment. J Am Coll Cardiol. 2015; 65(8):846-855. PMC: 4344871. DOI: 10.1016/j.jacc.2014.11.041. View

11.

Bhatt D, Steg P, Ohman E, Hirsch A, Ikeda Y, Mas J . International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006; 295(2):180-9. DOI: 10.1001/jama.295.2.180. View

12.

Kubo T, Imanishi T, Takarada S, Kuroi A, Ueno S, Yamano T . Assessment of culprit lesion morphology in acute myocardial infarction: ability of optical coherence tomography compared with intravascular ultrasound and coronary angioscopy. J Am Coll Cardiol. 2007; 50(10):933-9. DOI: 10.1016/j.jacc.2007.04.082. View

13.

Xu Y, Mintz G, Tam A, McPherson J, Iniguez A, Fajadet J . Prevalence, distribution, predictors, and outcomes of patients with calcified nodules in native coronary arteries: a 3-vessel intravascular ultrasound analysis from Providing Regional Observations to Study Predictors of Events in the Coronary Tree.... Circulation. 2012; 126(5):537-45. DOI: 10.1161/CIRCULATIONAHA.111.055004. View

14.

Virmani R, Kolodgie F, Burke A, Farb A, Schwartz S . Lessons from sudden coronary death: a comprehensive morphological classification scheme for atherosclerotic lesions. Arterioscler Thromb Vasc Biol. 2000; 20(5):1262-75. DOI: 10.1161/01.atv.20.5.1262. View

15.

Stone G, Maehara A, Lansky A, De Bruyne B, Cristea E, Mintz G . A prospective natural-history study of coronary atherosclerosis. N Engl J Med. 2011; 364(3):226-35. DOI: 10.1056/NEJMoa1002358. View

16.

Libby P, Pasterkamp G, Crea F, Jang I . Reassessing the Mechanisms of Acute Coronary Syndromes. Circ Res. 2019; 124(1):150-160. PMC: 6447371. DOI: 10.1161/CIRCRESAHA.118.311098. View

17.

Yeh R, Sidney S, Chandra M, Sorel M, Selby J, Go A . Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med. 2010; 362(23):2155-65. DOI: 10.1056/NEJMoa0908610. View

18.

McManus D, Gore J, Yarzebski J, Spencer F, Lessard D, Goldberg R . Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI. Am J Med. 2010; 124(1):40-7. PMC: 3011975. DOI: 10.1016/j.amjmed.2010.07.023. View

19.

Naghavi M, Libby P, Falk E, Casscells S, Litovsky S, Rumberger J . From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part I. Circulation. 2003; 108(14):1664-72. DOI: 10.1161/01.CIR.0000087480.94275.97. View

20.

Asakura M, Ueda Y, Yamaguchi O, Adachi T, Hirayama A, Hori M . Extensive development of vulnerable plaques as a pan-coronary process in patients with myocardial infarction: an angioscopic study. J Am Coll Cardiol. 2001; 37(5):1284-8. DOI: 10.1016/s0735-1097(01)01135-4. View