Paul Dudley White was an astute observer of ischemic heart disease who emphasized the unity of acute myocardial infarction and chronic exertional angina as facets of the clinical expression of coronary atherosclerosis. He knew that plaque ulceration was a precipitator of thrombosis, but in the days before angiography was widely used, he reasoned that thrombosis occurred at sites of previous high-grade stenosis. He would be fascinated by the explosion of knowledge concerning the mechanisms of the two major expressions of coronary heart disease that has occurred since his death in 1973.

Any consideration of how symptoms arise in coronary atherosclerosis must begin with plaque. By early adult life, most individuals in developed countries will have some coronary plaques that, in pathological terms, are advanced. This simply means that within the plaque there has been considerable accumulation of extracellular lipid, lipid within foam cells of macrophage origin, and collagen produced by smooth muscle cells.