Is Coronary Atherosclerosis Considered CAD?
Yes, coronary atherosclerosis is definitively considered coronary artery disease (CAD), as atherosclerosis represents the primary pathological process underlying CAD. 1, 2
Terminology and Definition
The American Heart Association explicitly states that "coronary heart disease, which includes coronary atherosclerotic disease, myocardial infarction, acute coronary syndromes, and angina" represents a spectrum of the same underlying disease process, with "atherosclerotic coronary artery disease (CAD)" being the core pathologic entity. 1
- Atherosclerosis is the fundamental disease mechanism that defines CAD, characterized by progressive plaque formation in the coronary arterial wall. 2
- The European Society of Cardiology defines chronic coronary syndromes as clinical presentations arising from chronic diseases of the coronary arteries, with atherosclerosis being the primary driver. 3
- CAD encompasses the full spectrum from asymptomatic coronary atherosclerosis to symptomatic manifestations including stable angina, acute coronary syndromes, and myocardial infarction. 1, 3
Clinical Implications of This Equivalence
The recognition that atherosclerosis equals CAD fundamentally shifts treatment paradigms:
- Patients with coronary atherosclerosis detected on imaging (such as coronary CTA) have CAD even without symptoms or obstructive stenoses. 4
- The CAD-RADS classification system grades atherosclerotic disease severity from CAD-RADS 0 (no atherosclerosis) through CAD-RADS 5 (total occlusion), treating any detectable atherosclerosis as disease requiring management. 1
- Treatment should target the atherosclerotic process itself, not just symptoms or stenoses, as atherosclerosis was "previously considered a cholesterol storage disease" but is "currently viewed as an inflammatory disorder." 5
Pathophysiologic Basis
The disease process involves multiple interconnected mechanisms:
- Initial endothelial dysfunction precedes visible atherosclerotic changes and represents the earliest manifestation of coronary disease. 2
- Extracellular lipid accumulation progresses to fibrofatty plaques with fibrous cap formation. 2
- Plaque disruption triggers thrombogenesis, leading to acute coronary syndromes. 2
- Risk factors that promote epicardial atherosclerosis simultaneously cause endothelial dysfunction throughout the entire coronary tree, including microvascular territories. 2
Important Clinical Caveat
Not all CAD is purely atherosclerotic. The European Society of Cardiology recognizes that chronic coronary syndromes can arise from diseases of both the coronary arteries AND microcirculation, including coronary microvascular dysfunction (CMD), vasospasm, myocardial bridging, and congenital anomalies. 2, 3 However, atherosclerosis remains the predominant and defining pathology in the vast majority of CAD cases. 2, 5