Biomechanical Determinants of Plaque Erosion: Translational Implications and Precision Care

Plaque erosion is a major cause of acute coronary syndromes and is characterized by endothelial denudation, fibrous-cap integrity, and platelet-rich thrombosis. Advances in intracoronary optical coherence tomography have enabled in vivo identification of erosion, revealing unique clinical profiles and therapeutic opportunities, including selectively avoiding stents. Increasing evidence implicates local mechanical forces as central drivers of endothelial injury in erosion. Computational biomechanics, including fluid dynamics and emerging optical coherence tomography-based finite element analysis, allow detailed quantification of hemodynamic and structural stresses at plaque surfaces. These models provide mechanistic insights into how flow disturbance, plaque geometry, and wall stress may converge to trigger erosion. Integrating biomechanical signatures with erosion-associated biological pathways may refine risk stratification, guide conservative management, and identify new therapeutic targets. This review integrates fluid and emerging solid mechanics approaches with endothelial biology to provide a comprehensive mechanistic overview of plaque erosion and outlines priorities for translating biomechanics into precision care.