Our data are in keeping up with previous findings, showing that patients with atherosclerosis of the thoracic aorta have higher probability of coexisting coronary artery disease [
2‐
8]. In those series the positive predictive value of TEE varied between 64% and 95%, whereas the negative predictive value was consistently high (between 82 and 99%.), indicating that in the absence of echocardiographically assessed atherosclerotic plaque in the thoracic aorta the probability of coronary artery disease is unlikely. Furthermore, Khoury et al have demonstrated, that atherosclerotic plaques in patients with coronary artery disease were found predominantly in the descending aorta (in 93%) and in the aortic arch (in 80%), whereas the ascending aorta was the least involved (in 37%) [
9]. Atherosclerosis is a complex polygenic, multifactorial vascular disorder associated with many differing and changing metabolic, anatomic and clinical manifestations [
13]. The presence of atherosclerotic plaque in the thoracic aorta, as shown by chest x-ray, has been shown in previous studies to be correlated with an increased risk of cardiovascular death [
14,
15]. However, several studies have also demonstrated that the generation of acute coronary syndromes is not necessarily related to plaque severity rather to its morphology and complexity. From histopathologic and vascular biologic studies [
13,
16] plaque composition and vulnerability (type of lesion) rather than degree of stenosis (size of lesion) have emerged as crucial factors leading to sudden rupture of the plaque surface, usually with thrombosis superimposed, which underlies the great majority of infarctions. Angiographic studies also suggest that the most frequent situation giving rise to infarction is the occlusion of previously noncritical stenoses [
17], which are more prevalent than the possibly more dangerous severe stenoses [
18]. Taken together, these studies suggest that in two of three infarctions the culprit lesions had only mild to moderate stenosis on initial evaluation in a substantial number of patients. This is again consistent with our finding that significant coronary artery disease is in close relationship with the atherosclerosis of the aorta but more severe the atherosclerosis is, higher the probability of spontaneous cardiovascular events.