Our preoccupation with coronary luminology : the dissociation between clinical and angiographic findings in ischemic heart disease

Nearly 40 years after its invention, the angiogram is still considered by most physicians to be the "gold standard" for defining coronary anatomy. Careful investigations have revealed many deficiencies inherent in this approach. The purpose of this article is to outline the evidence that o...

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Bibliographic Details
Published in:Circulation (New York, N.Y.) N.Y.), 1995-10, Vol.92 (8), p.2333-2342
Main Authors: TOPOL, E. J, NISSEN, S. E
Format: Article
Language:English
Subjects:
Angioplasty, Balloon, Coronary
Atherectomy, Coronary
Biological and medical sciences
Cardiology. Vascular system
Coronary Angiography - methods
Coronary Circulation
Coronary heart disease
Coronary Vessels - pathology
Heart
Humans
Image Processing, Computer-Assisted
Medical sciences
Myocardial Ischemia - diagnosis
Myocardial Ischemia - diagnostic imaging
Myocardial Ischemia - physiopathology
Myocardial Ischemia - therapy
Observer Variation
Radiology, Interventional
Recurrence
Stents
Thrombolytic Therapy
Ultrasonography, Interventional
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Summary:Nearly 40 years after its invention, the angiogram is still considered by most physicians to be the "gold standard" for defining coronary anatomy. Careful investigations have revealed many deficiencies inherent in this approach. The purpose of this article is to outline the evidence that our current preoccupation with coronary "luminology" may be misguided and to propose a rational paradigm for future practice and investigation. Angiography depicts coronary anatomy from a planar two-dimensional silhouette of the lumen. Angiography is limited in resolution to four or five line pairs per millimeter. Confounding factors include vessel tortuosity, overlap of structures, and the effects of lumen shape. After intervention, a hazy, broadened silhouette may overestimate the actual gain in lumen size. Studies show marked disparity between the apparent severity of lesions and their physiological effects. After myocardial infarction, cardiologists too often do not make an attempt to demonstrate the physiological significance of the stenosis before performing percutaneous coronary revascularization. Similarly, the allure of a better, more gratifying angiogram with new interventional devices appears to be a dominant factor in their popularity. Interventional cardiologists should be aware that techniques yielding marked angiographic benefit may also generate important but unrecognized hazards. The dissociation between the angiogram and clinical outcome should influence future research efforts. Our review of the literature indicates that we may benefit from shifting the current focus and preoccupation with coronary luminology to achieving the desired clinical end point: promoting survival and long-term freedom from myocardial infarction and the disabling symptoms of coronary heart disease.
ISSN:0009-7322
1524-4539
DOI:10.1161/01.CIR.92.8.2333