Book Review

The Vulnerable Atherosclerotic Plaque: Strategies for Diagnosis and Management

N Engl J Med 2007; 357:97-98July 5, 2007

Article

The Vulnerable Atherosclerotic Plaque: Strategies for Diagnosis and Management
Edited by Renu Virmani, Jagat Narula, Martin B. Leon, and James T. Willerson. 375 pp., illustrated. Malden, MA, Blackwell Futura, 2007. $174.95. ISBN: 978-1-4051-5859-6

This is a comprehensive, well-written, beautifully illustrated book about the disruption of atherosclerotic plaque. Plaque disruption is responsible for more than 75% of acute cardiac events, including myocardial infarction and sudden death. Heart disease has been the leading cause of death in the United States for the past 80 years, and a great majority of these deaths are caused by atherosclerotic coronary artery disease. Epidemiologists tell us that age-standardized mortality rates for myocardial infarction have declined over the past 10 to 15 years. However, the absolute number of deaths from myocardial infarction has actually increased, and now the mortality rate is even higher in women than men.

In the United States, approximately 1.1 million people a year have a myocardial infarction, and sudden death occurs in an estimated 500,000 people. Worldwide, cardiovascular disease is the major cause of death in developed countries, and its prevalence is increasing in the developing countries of South America and Asia. The epidemic of obesity and associated type 2 diabetes, in addition to increased smoking among certain populations, is likely to keep atherosclerotic cardiovascular disease a major killer for years to come. The economic costs are high as well — estimated at more than $150 billion in the United States in 2007.

The term “vulnerable plaque” refers to atherosclerotic plaque that is particularly susceptible to disruption, resulting in coronary-artery occlusion by overlying thrombi. It is now recognized that such plaques are present throughout the coronary arterial tree (“vulnerable artery”) and are associated with systemic risk factors (“vulnerable patient”). Atherosclerotic plaque rupture and thrombosis were first described more than 100 years ago. Although much has been written about them since that time, these acute changes have gained the recognition they deserve only in the past 20 to 30 years, as diagnostic techniques and therapeutic options for acute coronary syndromes have evolved. Considering the relevance of vulnerable plaque to human disease, devoting an entire book to the topic seems justifiable.

Photomicrograph Showing Rupture of Atherosclerotic Plaque.

Despite the importance of vulnerable plaque, one might still question the need for a 375-page book about this single lesion. For anyone interested in atherosclerotic cardiovascular disease, however, the answer is surely yes. The authors and editors of this book have done a masterful job, creating a comprehensive, authoritative, and remarkably up-to-date work on the vulnerable atherosclerotic plaque. Anyone who wishes to become knowledgeable about the vulnerable plaque, or to review the important literature on this topic, need only read this one book. The authors and editors are leading experts on this subject, and the four editors coauthored many of the chapters, which cover a wide range of topics related to vulnerable plaque.

The book begins with a fascinating chapter on the history of atherosclerosis, in which due credit is given to early investigators who have not always been recognized for their seminal observations and contributions. Next, a number of chapters cover the pathology of atherosclerosis and the vulnerable plaque in great detail. Although there is a consensus among pathologists and basic scientists regarding risk factors and triggers for plaque rupture, the exact pathogenesis is not completely understood. Predicting when or where a plaque will rupture is no easier than predicting an earthquake. There is no experimental model that truly mimics plaque disruption in human coronary arteries. Nevertheless, current knowledge and theories of the pathogenesis of plaque disruption, including physical factors, inflammatory and matrix changes, and apoptosis, are covered thoroughly and fairly in this book.

A particularly comprehensive and remarkably up-to-date portion of the book deals with evolving methods for the identification of vulnerable plaques. These approaches include the use of circulating biomarkers; established imaging techniques such as ultrasonography, magnetic resonance imaging, computed tomography, and radionuclide imaging; and a wide array of evolving imaging techniques that include near-infrared spectroscopy, thermography, optical coherence tomography, and palpography, an intravascular technique used to evaluate the local mechanical properties and components of tissue (I didn't know what this was either). In a field that is rapidly evolving, the editors have commissioned expert authors to provide timely chapters on these subjects. The book ends with five chapters on innovative potential interventions for treating vulnerable plaques, such as photodynamic therapy, thermal stabilization, and genetic modulation of atherosclerotic plaques.

As a reviewer, I would not be fulfilling my obligation if I did not try to find something negative to say about the book, but I have failed in this task. All of the chapters are well written, factual, loaded with information, well referenced, and beautifully illustrated with many high-quality images. This book should be on the shelf or desk of anyone who is interested in atherosclerosis and wishes to have access to a single, comprehensive source of information about the vulnerable plaque.

Michael C. Fishbein, M.D.
David Geffen School of Medicine at UCLA, Los Angeles, CA 90095