Fisiopatología de los síndromes coronarios agudos. Tres paradigmas para un nuevo dogma

Acute coronary syndromes are a group of clinical entities with a common denominator: the partial or total obstruction of a coronary artery by a thrombosis caused by rupture or erosion of a vulnerable plaque. This translates as clinical complications secondary to ischemica or myocardial necrosis. The significant incidence of cardiovascular events in industrialized countries and their notable increase in developing countries have a huge impact on socioeconomic resources in addition to truncating lives at the peak of a person's productivity and social usefulness. Novel advances in genetics and molecular biology have shed light on atherogenesis, the main etiological substrate in acute coronary syndromes, taking us to new horizons. Endothelial dysfunction and its interaction with newly described factors such as the immunity-inflammation axis, cell apoptosis, and the role of tissue factor and other factors, are some starting points. In addition, valuable information has come from studies of the various factors that favor hypercoagulability (vulnerable blood). Taken together, these new factors lead us to the concept of the high-risk patient with a vulnerable or high-risk plaque associated with vulnerable blood, vulnerable myocardium, or both. The three paradigms for a dogma are represented in this new scenario by the outstanding advances in our knowledge of pathophysiology (first paradigm), which leads us necessarily to a new diagnostic focus on-among other factors-multiple biomarkers and novel imaging techniques for characterizing high-risk plaques (second paradigm). The substantial contributions from these two areas will merge with new combined therapeutic strategies (third paradigm) underpinned by the control of inflammation and immunomodulation. In anticipation of the findings of studies now under way based on evidence-based medicine, it is expected that subsequent findings will allow us to clearly demonstrate the transcendence of this hypothesis and lead us to a dogma, or doctrine, based on these novel concepts.