LAUSR

Management of patients with calcified coronary arteries is problematic. It is difficult to assess lesion severity because the density of calcium is similar to radiographic contrast, thus the operator often underestimates the severity of the lesion. Once a decision is made to perform percutaneous coronary intervention (PCI), severe coronary calcification may create difficulty in wiring, tracking of balloons and devices, difficulty dilating the lesion and is associated with worse angiographic outcomes (dissection, perforation, failure to dilate, asymmetric and under-expanded stents) as well as worse clinical outcomes compared to non-calcified lesions. In the past it has been thought that calcified lesions were chronic, and lesions responsible for acute coronary syndromes (ACS) were typically soft, ulcerated, non-calcified lesions. However, in this issue of the Journal, amonganACS trial of827patients, 43%were found tohave moderate to severe calcified target lesions. As expected, patients with calcified lesions were older, and more likely to have hypertension, diabetes, peripheral disease and prior stroke. Surprisingly, procedure success was similar in both groups but calcified lesions required more frequent preand post-dilation. Unlike short-term studies, this trial reported 5 year follow-up and found an increased incidence of cardiac death,MI anddefinite stent thrombosis inpatientswith calcified lesions. However, in propensity matched analysis the outcome was similar, suggesting that other co-morbidities contributed to higher event rates. This study is limitedby inclusionof “moderate” calcified lesions, and lack of information regarding results in the “heavily” calcified group. It also would have been helpful to have data on balloon compliance, inflation pressures, and use of atherectomy devices.