Evaluation and Management of the Vulnerable Plaque

Abstract

Coronary plaque rupture is the dominant mechanism of acute myocardial infarction and sudden coronary death. If we are to make a major inroads on reducing morbidity and mortality from cardiovascular disease, more accurate prediction of an individual’s near-term cardiovascular risk (i.e., prediction of future coronary events) than what we can offer today is the ultimate goal to enable a more patient-tailored treatment strategy for coronary artery disease. In this review, we address the value of the vulnerable plaque concept in the context of an integrative cardiovascular risk assessment. Even with today’s state-of-the-art intravascular and non-invasive imaging, the identification of plaques at high-risk for rupture remains an elusive task albeit one in which important progress continues to be made. The vulnerable plaque concept emerged from the identification of morphological characteristics associated with plaque rupture as identified by autopsy studies. However, morphology alone may only be one of many factors which drive plaque progression. Therefore, the usefulness of the classical vulnerable plaque concept for predicting an individual’s cardiovascular risk clearly remains in the research realm. Nonetheless, the potential of being able to predict events before they happen remains an issue of utmost importance for cardiology. The identification of patients at risk for adverse cardiovascular events requires a comprehensive risk assessment. Invasive and non-invasive coronary imaging techniques allow for a detailed detection of vulnerable plaque characteristics. In combination with systemic factors that increase the disease’s activity, the finding that an individual may harbor coronary plaques with vulnerable characteristics indicates elevated atherosclerotic disease risk and thus justifies a more intensive therapeutic approach.