Plaque vulnerability and cardiovascular risk factor burden in acute coronary syndromes: insights from optical coherence tomography

PURPOSE OF REVIEW: Both cardiovascular risk factors and features of coronary plaque vulnerability are associated with adverse cardiovascular outcomes, including acute coronary syndromes (ACS); however, these epidemiological and pathological concepts have evolved along largely separate tracks. This review discusses emerging evidence that modifiable cardiovascular risk factor burden is associated with plaque vulnerability, as assessed by optical coherence tomography (OCT). RECENT FINDINGS: Recent large-scale OCT analyses suggest that, in patients with ACS, increasing modifiable cardiovascular risk factor burden is associated with a stepwise increase in culprit plaque features of vulnerability, including lipid-rich plaque, thin-cap fibroatheroma, macrophage accumulation, microvessels, and cholesterol crystals. This association was weaker in nonculprit plaques. In contrast, nonmodifiable risk factor burden was not associated with plaque vulnerability. These findings extend previous studies of individual risk factors by showing that cumulative modifiable risk burden is reflected in plaque phenotype. SUMMARY: Current evidence supports the concept that cumulative modifiable cardiovascular risk factor burden may reflect coronary plaque biology, linking epidemiological risk assessment with imaging-defined plaque vulnerability. In this framework, cardiovascular risk factor burden may be understood as a surrogate of plaque vulnerability, linked to inflammatory, oxidative, and metabolic pathways. This association may help identify higher risk patients.