Myocardial infarction, stroke and arterial stenosis: time to reassess a major misunderstanding.

A misconception persisting among the scientific and clinical communities relates to the correlation between arterial stenosis and acute ischaemic events, including myocardial infarction and cerebral stroke. This Perspective article challenges the approach that most of the current guidelines codify, which is based on the concept that occlusive arterial stenosis generally provokes ischaemic events. We highlight the mechanistic differences between chronic or inducible ischaemia caused by flow-limiting stenoses and acute thrombotic events and question the traditional reliance on stenosis grading as a biomarker for therapeutic decision-making that many guidelines enshrine. Furthermore, we review the latest evidence highlighting the lack of a correlation between stenosis severity and the occurrence of acute thrombotic complications of atherosclerosis, in the light of a major clinical trial that included a large contemporary population and showed that only one-third of major adverse cardiovascular events occur in individuals with obstructive coronary artery disease. These considerations aim to foster a shift, grounded in contemporary evidence, towards treatment approaches that address modifying plaque biology rather than stenoses per se, using pharmacological treatment as a fundamental factor in risk mitigation and moving away from sole reliance on stenosis grading as a primary determinant of therapeutic decisions.