CT evaluation of vulnerable plaque: noninvasive fortune-telling?

Recently, cardiac CTA has been proposed as a promising noninvasive tool for identification of rupture-prone plaques prior to a subsequent coronary event. This task is particularly challenging but the reward is high: identification of high-risk lesions could preclude plaque thrombosis and possibly prevent acute coronary syndromes. We present a case of a borderline mixed plaque with positive remodeling in the proximal left anterior descending artery (LAD). After 6 months and despite aggressive medical therapy, the patient developed acute ST-elevation myocardial infarction caused by a thrombotic lesion in the proximal LAD. We review the literature on CT characteristics of vulnerable plaque and discuss the possible preventive interventions.