At EuroPCR 2026, leading cardiologists tackled a critical question: can identifying and treating high-risk, or vulnerable, coronary plaque prevent future heart attacks?
Hector Garcia-Garcia of MedStar Washington Hospital Center outlined key identifiers: a large plaque burden over 70%, lipid-rich composition, and a thin fibrous cap. Intravascular ultrasound (IVUS) is the preferred tool for assessment.
Francesco Prati from San Giovanni Addolorata Hospital argued that fibrous cap thickness is the most critical marker, citing data showing thin-cap plaques carry a much higher risk of death and heart attack. He advocates combining multiple imaging features for a more accurate risk profile.
The core controversy is treatment. Elvin Kedhi of Royal Victoria Hospital stated that plaque vulnerability, not just artery blockage, is the true substrate for future events. He believes vulnerable plaque should be a primary target for preventive intervention.
A clinical case illustrated this: a patient with intermediate, non-blocked lesions showing vulnerable plaque features on imaging later suffered an acute coronary syndrome from one of those lesions.
However, not all experts are convinced. Peter Libby of Mass General Brigham cautioned that advances in medical therapy may be as important as device-based treatments, urging caution with permanent implants until stronger evidence emerges.
The future may lie in better biology, not just morphology. Libby highlighted photon-counting CT as a transformative technology for assessing coronary inflammation. The ongoing VULNERABLE trial will test whether preventive treatment of high-risk plaques improves outcomes.
The consensus: advanced imaging can now spot high-risk plaque, but clear guidelines on when and how to treat them are still missing.