EDITORIAL COMMENT Lesion characteristics and subsequent atherosclerotic disease progression. Insights into the dynamic process of coronary atherosclerosis Paul Schoenhagen Published online: 10 January 2008 Ó Springer Science+Business Media B.V. 2007 The goal of coronary imaging with conventional coronary angiography is the identification of focal culprit lesions causing acute or chronic symptoms. Subsequent treatment decisions are based on this static observation of symptomatic, advanced stages of coronary artery disease (CAD). However, coronary atherosclerosis begins much earlier and is a highly dynamic, systemic process with gradual plaque build- up and intermittent superimposed sudden changes causing asymptomatic accelerated progression or symptomatic, focal complications [1]. An attractive diagnostic approach would be the identification of lesion characteristics associated with future progression before events occur. This approach is described with the concept of the ‘‘vulnerable plaque/vulnerable patient’’. Treatment decisions based on such knowledge, reflecting the dynamic atherosclerotic disease process, would allow early initiation of risk factor modification and presumably prevention of coronary events. Current knowledge of vulnerable plaques has evolved from histologic observations in patients who died of acute events [2, 3]. These static observations have identified a number of high-risk lesion characteristics including a large necrotic core, a thin fibrous cap, expansive remodeling, and lesion inflam- mation. The dynamic, temporal changes of high-risk lesions are incompletely understood. Retrospective angiographic description of lesions subsequently causing acute coronary events demonstrates that many of these lesions are mildly stenotic prior to the event, but undergo rapid dynamic changes in the time period shortly before and after the event [4, 5]. These luminal changes reflect changes of the vessels wall/plaque, which can be visualized with tomographic imaging modalities, including intravascular ultrasound (IVUS). Using IVUS, a previous study identified and described coronary sites with atherosclerotic plaque but without significant stenosis at baseline [6]. During 2-year follow-up, a small number of patients had an acute coronary event at a previously examined coronary site. Retrospective review of the IVUS findings at these sites demonstrated, that there was no statistically significant difference in baseline lumen area between lesions with and without subsequent event. However, the preexisting plaques related to the acute events exhibited a greater plaque burden, an eccentric distribution, expansive remodel- ing, and a higher frequency of echolucent zones, likely representing a necrotic core. These in vivo results confirm the histologic findings [2, 3]. In the current issue of the journal, Leber et al. describe multi-slice computed tomography (MSCT) characteristics of coronary lesions with and without subsequent angiographic progression, defined as an P. Schoenhagen (&) Imaging Institute, Heart and Vascular Institute, The Cleveland Clinic, Cardiovascular Imaging, Desk HB-6, 9500, Euclid Avenue, Cleveland, OH 44195, USA e-mail: schoenp1@ccf.org 123 Int J Cardiovasc Imaging (2008) 24:429–431 DOI 10.1007/s10554-007-9291-z