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

Vergallo, Rocco ; Park, Seung Jung ; Stone, Gregg W. ; Erlinge, David LU orcid ; Porto, Italo ; Waksman, Ron ; Mintz, Gary S. ; D'Ascenzo, Fabrizio ; Seitun, Sara and Saba, Luca , et al. (2025) In JACC: Cardiovascular Imaging 18(6). p.709-740
Abstract

The concept of high-risk plaque emerged from pathologic and epidemiologic studies 3 decades ago that demonstrated plaque rupture with thrombosis as the predominant mechanism of acute coronary syndrome and sudden cardiac death. Thin-cap fibroatheroma, a plaque with a large lipidic core covered by a thin fibrous cap, is the prototype of the rupture-prone plaque and has been traditionally defined as “vulnerable plaque.” Although knowledge on the pathophysiology of plaque instability continues to grow, the risk profile of our patients has shifted and the character of atherosclerotic disease has evolved, partly because of widespread use of lipid-lowering therapies and other preventive measures. In vivo intracoronary imaging studies indicate... (More)

The concept of high-risk plaque emerged from pathologic and epidemiologic studies 3 decades ago that demonstrated plaque rupture with thrombosis as the predominant mechanism of acute coronary syndrome and sudden cardiac death. Thin-cap fibroatheroma, a plaque with a large lipidic core covered by a thin fibrous cap, is the prototype of the rupture-prone plaque and has been traditionally defined as “vulnerable plaque.” Although knowledge on the pathophysiology of plaque instability continues to grow, the risk profile of our patients has shifted and the character of atherosclerotic disease has evolved, partly because of widespread use of lipid-lowering therapies and other preventive measures. In vivo intracoronary imaging studies indicate that superficial erosion causes up to 40% of acute coronary syndromes. This changing landscape calls for broader perspective, expanding the concept of high-risk plaque to the precursors of all major substrates of coronary thrombosis beyond plaque rupture. Other factors to take into consideration include dynamic changes in plaque composition, the importance of plaque burden, inflammatory activation (both local and systemic), healing mechanisms, regional hemodynamic pattern, properties of the fluid phase of blood, and the amount of myocardium at risk subtended by a lesion. Rather than the traditional focus limited to the thin-cap fibroatheroma, the authors advocate a more comprehensive approach that considers both morphologic features and biological activity of plaques and blood. This position paper highlights the challenges to the usual concept of high-risk plaque, proposes a broader definition, and analyzes its key morphologic features, the technological progress of plaque imaging (particularly using intracoronary imaging techniques), advances in pharmacologic therapies for plaque regression and stabilization, and the feasibility and efficacy of focal interventional treatments including preemptive plaque sealing.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
acute coronary syndrome, erosion, high-risk plaque, imaging, lipid-lowering therapies, outcome, preemptive stenting, rupture, thin-cap fibroatheroma, thrombosis, vulnerable plaque
in
JACC: Cardiovascular Imaging
volume
18
issue
6
pages
32 pages
publisher
Elsevier
external identifiers
  • pmid:40019413
  • scopus:105000467451
ISSN
1936-878X
DOI
10.1016/j.jcmg.2024.12.004
language
English
LU publication?
yes
id
6a1fc594-806b-44a5-9bbc-ece702c03283
date added to LUP
2025-09-15 13:01:53
date last changed
2025-10-14 11:57:31
@article{6a1fc594-806b-44a5-9bbc-ece702c03283,
  abstract     = {{<p>The concept of high-risk plaque emerged from pathologic and epidemiologic studies 3 decades ago that demonstrated plaque rupture with thrombosis as the predominant mechanism of acute coronary syndrome and sudden cardiac death. Thin-cap fibroatheroma, a plaque with a large lipidic core covered by a thin fibrous cap, is the prototype of the rupture-prone plaque and has been traditionally defined as “vulnerable plaque.” Although knowledge on the pathophysiology of plaque instability continues to grow, the risk profile of our patients has shifted and the character of atherosclerotic disease has evolved, partly because of widespread use of lipid-lowering therapies and other preventive measures. In vivo intracoronary imaging studies indicate that superficial erosion causes up to 40% of acute coronary syndromes. This changing landscape calls for broader perspective, expanding the concept of high-risk plaque to the precursors of all major substrates of coronary thrombosis beyond plaque rupture. Other factors to take into consideration include dynamic changes in plaque composition, the importance of plaque burden, inflammatory activation (both local and systemic), healing mechanisms, regional hemodynamic pattern, properties of the fluid phase of blood, and the amount of myocardium at risk subtended by a lesion. Rather than the traditional focus limited to the thin-cap fibroatheroma, the authors advocate a more comprehensive approach that considers both morphologic features and biological activity of plaques and blood. This position paper highlights the challenges to the usual concept of high-risk plaque, proposes a broader definition, and analyzes its key morphologic features, the technological progress of plaque imaging (particularly using intracoronary imaging techniques), advances in pharmacologic therapies for plaque regression and stabilization, and the feasibility and efficacy of focal interventional treatments including preemptive plaque sealing.</p>}},
  author       = {{Vergallo, Rocco and Park, Seung Jung and Stone, Gregg W. and Erlinge, David and Porto, Italo and Waksman, Ron and Mintz, Gary S. and D'Ascenzo, Fabrizio and Seitun, Sara and Saba, Luca and Vliegenthart, Rozemarijn and Alfonso, Fernando and Arbab-Zadeh, Armin and Libby, Peter and Di Carli, Marcelo F. and Muller, James E. and Maurer, Gerald and Gropler, Robert J. and Chandrashekhar, Y. S. and Braunwald, Eugene and Fuster, Valentin and Jang, Ik Kyung}},
  issn         = {{1936-878X}},
  keywords     = {{acute coronary syndrome; erosion; high-risk plaque; imaging; lipid-lowering therapies; outcome; preemptive stenting; rupture; thin-cap fibroatheroma; thrombosis; vulnerable plaque}},
  language     = {{eng}},
  number       = {{6}},
  pages        = {{709--740}},
  publisher    = {{Elsevier}},
  series       = {{JACC: Cardiovascular Imaging}},
  title        = {{Vulnerable or High-Risk Plaque : A JACC: Cardiovascular Imaging Position Statement}},
  url          = {{http://dx.doi.org/10.1016/j.jcmg.2024.12.004}},
  doi          = {{10.1016/j.jcmg.2024.12.004}},
  volume       = {{18}},
  year         = {{2025}},
}