Pathophysiology of vascular endothelium and circulating platelets: implications for coronary revascularisation and treatment

Constant vasodilatation, inhibition of platelet and leukocyte adhesion, and local thrombolysis are the mechanisms through which an intact endothelial layer exerts its protective action on coronary circulation. A loss in these features is not only the first step in the development of atherosclerosis, but also a potent trigger for complications after revascularisation proced ures. Percutaneous coronary interventions, particularly in the course of st enting, induce endothelial injury that can last up to months after the proc edure. On the other hand, the preservation of endothelial function appears the best feature of arterial versus venous grafts after coronary bypass sur gery. An early diagnosis either by invasive or non-invasive techniques has important implications for prognosis, and endothelial dysfunction can be ef fectively counteracted by medical treatment (ACE inhibitors, statins). Acti vated circulating platelets are present in the course of coronary artery di sease, increasing the risk of thrombotic occlusion and/or plaque regrowth, after both percutaneous and surgical revascularisation. New antiplatelet ag ents are under development to reduce endothelium-platelet interaction. On t he basis of the latest studies, coronary revascularisation should be integr ated in a more complete treatment, which would take into account the comple x processes involving the underlying atherosclerotic plaque. (C) 2001 Elsev ier Science Ireland Ltd. All rights reserved.