A perspective of coronary disease seen through the arteries of living man.

"A LONG DISPUTE," Voltaire (himself an incorrigible disputant) was fond of saying, "means both parties are wrong." Cardiology's longest debate concerns the pathogenesis of acute coronary disease. Today the resolution seems at hand: thrombus is once again the cause of acute infarction and thrombolysis is its cure. We do not wish to say, as Voltaire might, that this consensus is wrong, but it is incomplete because it leaves unanswered a crucial set of pathophysiologic questioins: What events precede coronary thrombosis? After formation of thrombus begins, are there fates other than infarction? At what points can the evolution of any of the acute (or chronic) coronary syndromes be arrested? Our Perspective proposes a systematic description-a paradigm-of the pathophysiology of acute and chronic coronary artery disease in man that deals specifically with these three questions. In the past year we have taken a metaphoric voyage through the coronary arteries of living man, using fiberoptic angioscopes. Through this exploration, we have seen the coronary endothelial surface in both acute and chronic coronary syndromes. Our unanticipated discovery has been that each of the common clinical presentations seems to have a specific, identifiable endothelial pathology. We will first describe