Uncovering Plaque Erosion: A Distinct Pathway in Acute Coronary Syndromes and a Gateway to Personalized Therapy

Abstract

Plaque erosion (PE) is now recognized as a common and clinically significant cause of acute coronary syndromes (ACSs), accounting for up to 40% of cases. Unlike plaque rupture (PR), PE involves superficial endothelial loss over an intact fibrous cap and occurs in a low-inflammatory setting, typically affecting younger patients, women, and smokers with fewer traditional risk factors. The growing recognition of PE has been driven by high-resolution intracoronary imaging, particularly optical coherence tomography (OCT), which enables in vivo differentiation from PR. Identifying PE with OCT has opened the door to personalized treatment strategies, as explored in recent trials evaluating the safety of deferring stent implantation in selected cases in favor of intensive medical therapy. Given its unexpectedly high prevalence, PE is now recognized as a common pathophysiological mechanism in ACS, rather than a rare exception. This growing awareness underscores the importance of its accurate identification through OCT in clinical practice. Early recognition and a deeper understanding of PE are essential steps toward the implementation of precision medicine, allowing clinicians to move beyond "one-size-fits-all" models toward "mechanism-based" therapeutic strategies. This narrative review aims to offer an integrated overview of PE, tracing its epidemiology, elucidating the molecular and pathophysiological mechanisms involved, outlining its clinical presentations, and placing particular emphasis on diagnostic strategies with OCT, while also discussing emerging therapeutic approaches and future directions for personalized cardiovascular care.

Keywords: acute coronary syndromes; optical coherence tomography; personalized care; plaque erosion.

Figure 1

Plaque rupture and plaque erosion. Panel (A): Plaque rupture with evidence of fibrous cap discontinuity resulting in two distinct cavities in the vessel wall at 12 and 6 o’clock (dashed arrow), with irregularities of the luminal surface (solid arrow). The underlying plaque is lipid-rich, characterized by a low-backscattering zone with poorly defined borders (extending from 12 to 6 o’clock) and a high-backscattering fibrous cap of variable thickness. Panel (B): Plaque erosion with a mixed thrombus overlying an intact fibrous cap. The asterisks indicate the guide wire artifact. All images come from the authors’ personal archive.

Figure 2

Types of thrombi in plaque erosion. Panel (A): Plaque erosion over a likely lipid-rich plaque, associated with a red thrombus (white arrow), characterized by high backscattering and significant light attenuation, resulting in shadowing that obscures the underlying plaque. Panel (B): Erosion with a white thrombus (white arrow), showing more moderate signal intensity and less attenuation, allowing visualization of the underlying lipid plaque. Panel (C): Erosion with a mixed thrombus (white arrow), which displays intermediate characteristics, combining features of both red and white components. The asterisks indicate the guide wire artifact. All images come from the authors’ personal archive.

Figure 3

Plaque phenotype underlying plaque erosion. Panel (A): PE with a mixed thrombus (white arrow) over a fibrous plaque, characterized by loss of the typical three-layered architecture and appearance of a homogeneous high-intensity signal region (white curved line). Panel (B): PE with a mixed thrombus (white arrow) that allows visualization of the underlying lipid plaque, identified as a low-backscattering zone with poorly defined borders and an angular extension < 90° (white curved line). Panel (C): PE with a white thrombus in the setting of a stenosis with diffuse calcification. Calcium appears as a region with low backscattering, heterogeneous signal, and sharply defined borders. The calcified arc exceeds 90° (white curved line), consistent with diffuse calcification. Panel (D): PE with a mixed thrombus (solid white arrow) over a lipid plaque (white curved line), which shows features of healing (dashed arrow), such as a distinct superficial layer with heterogeneous optical signal and clear demarcation from the underlying tissue. The asterisks indicate the guide wire artifact. All images come from the authors’ personal archive.