Vulnerable or High-Risk Plaque: A JACC: Cardiovascular Imaging Position Statement

Area of Science:

• Cardiology
• Pathology
• Biomedical Engineering

Background:

• High-risk plaque, traditionally defined as thin-cap fibroatheroma prone to rupture, has been linked to acute coronary syndromes.
• Shifting patient risk profiles and evolving atherosclerotic disease due to preventive therapies necessitate a re-evaluation of high-risk plaque concepts.
• Intracoronary imaging reveals superficial erosion causes up to 40% of acute coronary syndromes, challenging the sole focus on plaque rupture.

Purpose of the Study:

• To propose a broader definition of high-risk plaque beyond traditional rupture-prone morphology.
• To analyze key morphologic features, technological advancements in plaque imaging, and therapeutic strategies for plaque stabilization and regression.
• To discuss the feasibility and efficacy of interventional treatments for high-risk atherosclerotic lesions.

Main Methods:

• Review of pathologic and epidemiologic studies on plaque rupture and thrombosis.
• Analysis of in vivo intracoronary imaging data on plaque erosion.
• Synthesis of current knowledge on plaque composition, inflammation, healing, hemodynamics, and blood properties.
• Evaluation of technological progress in plaque imaging and interventional treatments.

Main Results:

• The concept of high-risk plaque needs expansion to encompass precursors of all coronary thrombosis substrates, not just plaque rupture.
• Factors such as dynamic plaque changes, burden, inflammation, healing, hemodynamics, and blood properties are crucial.
• Intracoronary imaging techniques have advanced significantly for plaque characterization.
• Pharmacologic and interventional therapies show promise for plaque regression, stabilization, and sealing.

Conclusions:

• A comprehensive approach to high-risk plaque should integrate morphologic features with biological activity of plaques and blood.
• The traditional focus on thin-cap fibroatheroma is insufficient; a broader definition encompassing erosion and other thrombotic substrates is advocated.
• Technological and therapeutic advancements offer new avenues for managing high-risk atherosclerotic disease and preventing adverse cardiovascular events.