The angiographic spectrum of coronary artery disease.

A wide spectrum of coronary arteriographic anatomic findings exists in patients presenting with clinically stable and unstable angina pectoris. Although some generalizations about the clinical-angiographic correlations can be made, we are continuously reminded of the frequent individual patient whose findings fall well outside of these generalizations. The majority of patients will have double- or triple-vessel coronary disease, with approximately 10 percent having in addition a left main coronary artery stenosis of at least 50 percent luminal diameter narrowing. Patients with unstable angina tend to have slightly greater vessel involvement in terms of lesion severity, though major differences, in general, are not seen. Intracoronary thrombus is present more frequently in patients with unstable angina and in those with recent myocardial infarction, though the overall incidence of this finding is low. Knowledge of the anatomic extent of coronary atherosclerosis is useful for determining prognosis and for selection from an ever-increasing variety of medical and surgical treatment options. Cardiac imaging is a continuously evolving field with new techniques such as digital angiography, three-dimensional dynamic imaging (dynamic spatial reconstructor), and nuclear magnetic resonance undergoing preclinical or clinical evaluation. These modalities hold promise for ultimately evaluating the coronary vessels from unlimited angles, assessing regional transmural myocardial perfusion and the cellular metabolic consequences of ischemia. However, current therapies (bypass surgery or coronary angioplasty) are based upon modifications of major epicardial coronary anatomy, and techniques that adequately define this anatomy are required. Moreover, for imaging data to have prognostic application, it must have previously established clinical prognostic correlates and be broadly applicable or widely available for patients. Thus for the present and immediate foreseeable future, coronary angiography will be the primary method for establishing the anatomic abnormalities of the coronary arteries, and these angiographic studies will remain vital for the clinical management of ischemic heart disease.