Angiographic plaque complexity: the tip of the unstable plaque iceberg.

Coronary plaque rupture is implicated in the pathogenesis of the acute coronary syndromes (1–9). Complex lesion morphology is the angiographic hallmark of these unstable ischemic syndromes, and it correlates with pathologic evidence of plaque rupture (7–9). In this issue of the Journal, Kerensky et al. (10) describe the angiographic patterns of plaque instability in 350 patients with nontransmural myocardial infarction (NQWMI) randomized to the invasive arm of the Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital (VANQWISH) trial (10). Observations from this study demonstrate that a complex culprit lesion could not be identified in nearly one-third of patients; in contrast, a significant number of patients harbored multiple unstable plaques.