Bibliographical note

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Conventional assessments of CAD focus on the identification of hemodynamically obstructive lesions. Multivessel obstructive disease has been shown to be associated with increased risk of adverse cardiac events compared to single-vessel disease.7,8 It is now being questioned, however, whether obstructive lesions hold independent prognostic information or if their presence merely reflects a large underlying plaque burden which subsequently drives adverse cardiac events. Chang et al.9 investigated the prognostic significance of lesion stenosis, independent of plaque burden, and found diameter stenosis to predict future ACS. Sensitivity using a ≥50 ​% stenosis threshold, however, was low and the authors recommend a combined assessment of plaque tissue volumes and high-risk plaque features at patient-level to guide risk assessment. These findings are supported by the work of Stone et al.26 who investigated the natural history of coronary atherosclerosis in 697 ACS patients using intravascular ultrasound imaging. These investigators found that stenosis (minimal luminal diameter ≤4 ​mm2) was associated with a 3-fold increased risk of ACS and plaque burden ≥70 ​% was associated with a 5-fold increased risk of ACS. The authors conclude that non-culprit lesions giving rise to a new ACS event were most often angiographically mild, were thin-cap fibroatheromas or were characterized by a large plaque burden, a small luminal area, or some combination of these characteristics. Overall, the volumetric assessment of CAD tissue type, and not just the identification of obstructive lesions, appears central for prognostic evaluation.MCK is supported by The Danish Heart Foundation (grant number 16-R107-A6719-22959) and Eva og Henry Frænkels Mindefond.

Funding Information:
MCK is supported by The Danish Heart Foundation (grant number 16-R107-A6719-22959) and Eva og Henry Frænkels Mindefond.

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