A new position paper is calling for an updated definition of high-risk plaque in coronary artery disease, as researchers highlight the need to move beyond the decades-old focus on rupture-prone lesions. Writing in the June 2025 issue of JACC: Cardiovascular Imaging, the authors of the paper urge clinicians and researchers to widen their comprehension of the factors that contribute to acute coronary syndromes (ACS). Led by Rocco Vergallo, MD, PhD2, from the Università di Genova in Genoa, Italy, the team said that this understanding should extend beyond rupture mechanisms and include plaque erosion and eruptive calcified nodules. Comprehensive approach “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,” wrote the global panel of cardiovascular experts. The review also discusses how high-risk plaques, defined as lesions likely to evolve into thrombosis and cause heart attacks or sudden cardiac death, are influenced by a wide range of structural and systemic factors. These include plaque burden, inflammation, local blood flow dynamics and the amount of heart muscle at risk. “The term ‘high-risk plaque’ should therefore be used to describe a plaque with increased propensity to evolve into a clinically relevant thrombosis,” wrote the authors. Plaque erosion The review reserves discussion for the growing role of plaque erosion, which now accounts for up to 40% of ACS cases and is often overlooked in standard assessments. Also an issue worthy of debate was the challenge of predicting and preventing first-time cardiac events, which are frequently catastrophic. Imaging technologies, particularly intravascular methods like optical coherence tomography (OCT) and intravascular ultrasound (IVUS) are aiding in the detection of plaque features. However, the authors warned that imaging alone may not be enough to reliably predict risk. The review goes on to call for a collective focus on plaque structure, systemic disease activity and emerging imaging biomarkers such as perivascular fat inflammation. The authors also suggested that silent plaque ruptures may be more common than previously suggested, subtly progressing without symptoms. They concluded by urging more intensified research efforts and refined strategies to identify and treat high-risk plaques before they caused harm and reiterated their goal of a more accurate assessment of high-risk plaques and their preemptive treatment. Sources: Vergallo R, Park SJ, Stone GW, et al. Vulnerable or High-Risk Plaque. A JACC: Cardiovascular Imaging Position Statement. JACC Cardiovasc Imaging. 2025;18(6):709-740. Image Credit: sudok1– stock.adobe.com