Coronary arteriography and lipid lowering: limitations, new concepts, and new paradigms in cardiovascular medicine.

Coronary arteriography has played a central role in improving our understanding of the mechanisms of unstable coronary syndromes and the benefits of cholesterol lowering. However, coronary arteriography as currently used is outmoded and inadequate for new clinical algorithms based on vigorous lipid and other risk factor control as alternatives to invasive procedures for the primary treatment of coronary artery disease. What is needed is a way of viewing or analyzing noninvasive myocardial perfusion images and coronary arteriograms so as to identify and quantify the extent or severity of diffuse coronary atherosclerosis. Determining the relative contribution of diffuse and segmental narrowing by definitive myocardial perfusion imaging or coronary arteriography would provide the optimal basis for determining the need for revascularization procedures. In the absence of significant segmental stenoses, mild or diffuse disease identified by coronary arteriography would also provide a definitive diagnosis as the basis for lifelong cholesterol-lowering drugs and risk factor modification, even for patients with normal cholesterol levels. Thus, it is important to consider several new concepts for analyzing coronary arteriograms. More physiologically accurate invasive and noninvasive technology allows improved diagnosis and management of coronary atherosclerosis as new paradigms in cardiovascular medicine.