Plaque Progression and Rupture in Obstructive Coronary Artery Disease: A Review of Current Imaging Modalities

Area of Science:

• Cardiovascular Medicine
• Medical Imaging
• Immunology

Background:

• Obstructive coronary artery disease (CAD) management faces residual risk due to unresolved vascular inflammation and plaque instability, despite optimal lipid-lowering therapies.
• Acute coronary syndromes are precipitated by vulnerable plaque rupture, not necessarily the most stenotic lesions.
• Understanding the mechanisms of plaque progression and rupture is crucial for improving patient outcomes.

Purpose of the Study:

• To review the mechanistic pathways of atherosclerotic plaque progression and rupture.
• To examine how various in vivo imaging modalities characterize these processes and track disease activity.
• To discuss therapeutic implications of plaque imaging for risk stratification and personalized prevention strategies.

Main Methods:

• Review of mechanistic pathways from endothelial dysfunction and lipoprotein oxidation to immune responses and biomechanical forces.
• Integration of in vivo imaging phenotypes, including intravascular ultrasound (IVUS), optical coherence tomography (OCT), near-infrared spectroscopy (NIRS), coronary computed tomography angiography (CCTA), cardiac magnetic resonance (CMR), and positron emission tomography (PET).
• Discussion of emerging therapeutic strategies targeting inflammation, immune pathways, and cap stability.

Main Results:

• Imaging techniques like IVUS, OCT, NIRS, CCTA, CMR, and PET can characterize vulnerable plaque features and enable longitudinal tracking of disease.
• These modalities provide insights into endothelial dysfunction, lipoprotein retention, inflammation, efferocytosis failure, and biomechanical cap stress.
• Plaque imaging aids in identifying unstable lesions that pose a higher risk of rupture and infarction.

Conclusions:

• Advanced imaging of atherosclerotic plaque offers a paradigm shift from stenosis-based revascularization to vulnerability-centered prevention.
• Improved identification of vulnerable plaque features can refine risk stratification and guide therapy.
• Serial imaging and biomarkers can support risk-adapted treatment strategies beyond lipid-lowering to modulate inflammation and enhance plaque stability.