The myth of ‘stable’ coronary artery disease

• Published in: Nature reviews cardiology 2020-01, Vol.17 (1), p.9-21
• Main Authors: Fox, Keith A. A., Metra, Marco, Morais, João, Atar, Dan
• Format: Article
• Language: English
• Subjects: 692/4019/592/75/593/15; 692/499; 692/700/459/1748; 692/700/565/1436; Angina pectoris; Blood clots; Cardiac Imaging; Cardiac Surgery; Cardiology; Cardiovascular disease; Cardiovascular research; Care and treatment; Coronary Artery Disease - classification; Coronary Artery Disease - diagnosis; Coronary Artery Disease - physiopathology; Coronary Artery Disease - therapy; Coronary heart disease; Coronary vessels; Development and progression; Diabetes; Disease prevention; Disease Progression; Evaluation; Health risk assessment; Humans; Medicine; Medicine & Public Health; Patients; Progression-Free Survival; Review Article; Risk Assessment; Risk Factors; Stroke; Terminology as Topic; Thrombosis; Time Factors; Ultrasonic imaging
• ISSN: 1759-5002; 1759-5010
• DOI: 10.1038/s41569-019-0233-y

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. Patients with known cardiovascular disease but no recent acute event are often referred to as having ‘stable’ coronary artery disease. In this Review, Fox and colleagues describe why this concept of stable disease is misleading and should instead be characterized as chronic disease with an increased risk of atherothrombotic events. Key points The clinical label ‘stable’ coronary artery disease (CAD) needs to be reconsidered and be more clearly defined as chronic coronary vascular disease, including patient groups at substantial risk of future coronary events. The risk of cardiovascular events in patients with chronic CAD is compounded by the presence of combined systemic and specific vascular risk factors. Chronic CAD requires optimal medical therapy to mitigate the effect of modifiable risk factors and to reduce the risk of cardiovascular events (such as myocardial infarction, stroke and cardiovascular death). Novel approaches might have the potential to reduce the risk of adverse events further, including profound lipid-lowering and inflammation-modifying agents and novel antithrombotic combinations. The latest advances demonstrate that chronic vascular risk is modifiable and doing so has the potential to produce clinically worthwhile gains in the most susceptible patients. The field will continue to evolve, with improv