Well into the 21st century, we still triage acute myocardial infarction on the basis of the presence or absence of ST-segment elevation, a century-old technology. Meanwhile, we have learned a great deal about the pathophysiology and mechanisms of acute coronary syndromes (ACS) at the clinical, pathological, cellular, and molecular levels. Contemporary imaging studies have shed new light on the mechanisms of ACS. This review discusses these advances and their implications for clinical management of the ACS for the future. Plaque rupture has dominated our thinking about ACS pathophysiology for decades. However, current evidence suggests that a sole focus on plaque rupture vastly oversimplifies this complex collection of diseases and obscures other mechanisms that may mandate different management strategies. We propose segmenting coronary artery thrombosis caused by plaque rupture into cases with or without signs of concomitant inflammation. This distinction may have substantial therapeutic implications as direct anti-inflammatory interventions for atherosclerosis emerge. Coronary artery thrombosis caused by plaque erosion may be on the rise in an era of intense lipid lowering. Identification of patients with of ACS resulting from erosion may permit a less invasive approach to management than the current standard of care. We also now recognize ACS that occur without apparent epicardial coronary artery thrombus or stenosis. Such events may arise from spasm, microvascular disease, or other pathways. Emerging management strategies may likewise apply selectively to this category of ACS. We advocate this more mechanistic approach to the categorization of ACS to provide a framework for future tailoring, triage, and therapy for patients in a more personalized and precise manner.

进入21世纪，我们仍然根据存在一个世纪历史的ST段抬高的存在来对急性心肌梗塞进行分类。同时，我们在临床，病理，细胞和分子水平上都学到了很多有关急性冠脉综合征（ACS）的病理生理学和机制的知识。当代影像学研究为ACS的机理提供了新的思路。这篇综述讨论了这些进展及其对ACS未来临床管理的影响。几十年来，斑块破裂一直主导着我们对ACS病理生理学的思考。但是，目前的证据表明，仅关注斑块破裂会极大地简化了这种复杂的疾病收集过程，并掩盖了可能要求采取不同管理策略的其他机制。我们建议将由斑块破裂引起的冠状动脉血栓形成细分为有或没有伴随炎症迹象的病例。随着对动脉粥样硬化的直接抗炎干预的出现，这种区别可能具有实质性的治疗意义。在血脂急剧下降的时代，由斑块侵蚀引起的冠状动脉血栓形成可能正在上升。识别由糜烂导致的ACS患者可能比目前的护理标准更具侵入性。现在，我们还认识到无明显心外膜冠状动脉血栓或狭窄发生的ACS。此类事件可能是由痉挛，微血管疾病或其他途径引起的。新兴的管理策略同样可以选择性地应用于此类ACS。