Acute coronary syndrome with plaque erosion: clinical characteristics, mechanisms, and unmet needs

Coronary plaque erosion is the second most common mechanism causing acute coronary syndromes (ACS), after coronary plaque rupture, accounting for approximately one-third of all ACS cases. The prevalence of coronary plaque erosion may be on the rise, likely due to more effective lipid-lowering therapy primarily targeted at the prevention of coronary plaque rupture. Moreover, the wider use of more refined diagnostic tools, including high-resolution intracoronary imaging modalities, has enabled more precise classification of ACS with eroded vs ruptured plaque. Optical coherence tomography (OCT) enables real-time detection of ACS with intact fibrous cap (IFC, plaque erosion) and ACS due to ruptured fibrous cap (RFC, plaque rupture), facilitating the development of potentially more personalized preventive therapeutic strategies in the future. A better understanding of specific pathological mechanisms underlying ACS due to plaque erosion has therefore become a major scientific focus over the past decade. This review explores advancements in comprehending the complex, multifaceted pathophysiology of ACS with plaque erosion and discusses potential therapeutic and preventive avenues for these patients.