VEXING NOTION DEFINITION SERIES

Unfortunately, the under-reporting of negative studies has not been eliminated following the development of mandatory registries such as. The resulting enthusiasm typically leads to overly optimistic expectations and occasionally clinical application by enthusiastic practitioners. Negative studies end up in a file drawer. When a promising new diagnostic method is reported, additional studies are performed, but only the “positive” studies are reported. The entire field is seemingly plagued by the vexing problem of negative publication bias. Yet, none of these methods have been properly validated via well-designed randomized controlled studies, and none have achieved routine clinical use. In each case, a technique for vulnerable plaque detection is developed, promoted, and widely hailed as a breakthrough, followed by “confirmation” via uncontrolled observational studies or registries. The list of failed techniques for vulnerable plaque detection seems almost endless: thermography, intravascular ultrasound (IVUS) virtual histology, optical coherence tomography, angioscopy, intravascular magnetic resonance, near-infrared spectroscopy (NIRS), intravascular elastography-palpography, multidetector computed tomography, and positron emission tomography. The rise and fall of coronary thermography is emblematic of a pattern that has recurred repeatedly during the last 2 decades.

A flurry of papers, mostly low-quality, uncontrolled studies, confirmed the presence of abnormal temperature readings in the coronary arteries of patients with unstable syndromes. In a frenzy of activity, companies were formed, inviting investors to fund efforts to develop coronary thermography as the next big thing. This research was met with an explosion of interest in finding so-called “hot” plaques. They reported that patients with normal coronaries showed uniform temperature, but that patients with unstable angina or acute myocardial infarction had significant “temperature heterogeneity” within culprit lesions. Then, in 1999, investigators based in Greece placed intracoronary catheters containing a highly accurate thermistor to measure the temperature of the vessel wall ( 2). The concept of vulnerable plaque was first proposed by Muller et al.

VEXING NOTION DEFINITION SERIES

Now, after a long series of failures, it seems abundantly clear that the entire concept of vulnerable plaque is fundamentally flawed and reflects an overly simplistic view of the pathophysiology underlying coronary events. In many cases, an underlying motivation for identifying vulnerable plaques is the notion that interventional cardiologists could place a stent within such plaques, thereby avoiding untoward outcomes.

Proponents of this concept have tried for decades to demonstrate the existence of a specific plaque phenotype that portends major adverse outcomes, such as myocardial infarction or sudden cardiac death. A quote often attributed to Albert Einstein defines insanity as “doing the same thing over and over again and expecting different results.” That’s exactly what has happened with efforts to identify the elusive entity of “vulnerable plaque” using various coronary imaging modalities.

Vexing notion definition