A new commentary published in Cardiology Discovery calls for reorienting coronary disease management away from treating symptomatic vessel blockages toward early detection and stabilization of atherosclerotic plaques, a shift intended to prevent acute myocardial infarction in high‑risk adults worldwide. The work responds to The Lancet Commission’s proposal to redefine coronary disease as atherosclerotic coronary artery disease, or ACAD, and provides practical, clinic‑ready recommendations adapted for diverse healthcare settings.
For decades, clinicians have largely focused on coronary stenosis and myocardial ischemia to guide diagnosis and treatment. This ischemia‑centered model frequently intervenes only after patients develop angina or suffer heart attacks. However, myocardial infarction can stem from plaque rupture even when arteries lack severe narrowing, creating a critical gap in early preventive care for millions of asymptomatic at‑risk individuals.
This article is a narrative expert commentary drawing on published population‑based epidemiologic data from China, including community-based data showing that 44.9% of adults aged 50‑75 years carry coronary atherosclerotic plaques, and more than one‑fifth of adults aged 20 and older have carotid plaques. The authors propose a risk‑stratified screening pathway targeting adults aged 40 or older with at least one traditional cardiac risk factor, such as hypertension, diabetes, dyslipidemia, or smoking. Stepwise evaluation starts with noninvasive tools including carotid ultrasound and coronary artery calcium scoring, rather than immediate use of costly intracoronary imaging. Intensified pharmacologic and lifestyle interventions are triggered by high‑risk plaque features or elevated coronary artery calcium scores, while routine stenting for non‑culprit vulnerable plaques is not supported by existing evidence.
The paper emphasizes that plaque stability depends not only on lipid levels but also on residual inflammatory risk and environmental exposures including fine particulate air pollution and traffic noise. Systemic guideline‑directed medical therapy, rather than mechanical revascularization alone, should serve as the foundation to stabilize plaques and avert future cardiovascular events.
Important limitations should temper widespread adoption. High‑cost advanced plaque imaging cannot be broadly deployed in resource‑limited regions. Standardization of image reading across centers remains incomplete, and definitive long‑term randomized controlled trial data proving that plaque‑targeted screening reduces hard clinical endpoints are still lacking. Anti‑inflammatory add‑on therapies also require further real‑world validation regarding safety and cost‑effectiveness. Moving forward, large prospective outcome studies and cost‑effectiveness analyses will help refine and validate this plaque‑centered care model for global clinical practice.
This article appears in Cardiology Discovery . DOI: 10.1097/CD9.0000000000000208
Cardiology Discovery
Commentary/editorial
Not applicable
Atherosclerotic Plaque vs . Coronary Stenosis: Redefining the Drivers of Coronary Artery Disease—Comment on the Lancet Commission
31-Jul-2026