Is Imaging of a Single Vessel Sufficient to Assess Pan‐Coronary Vulnerability?

BACKGROUND: Coronary atherosclerosis is a pan-coronary process. However, some studies investigated only one coronary artery and extrapolated the findings to the pan-vascular process. AIMS: We utilized a three-vessel optical coherence tomography (OCT) database to investigate whether plaque features in the left anterior descending coronary artery (LAD) mirror vulnerability in the remaining coronary vessels. METHODS: We analyzed 131 patients who underwent OCT imaging of the LAD, left circumflex (LCx), and right coronary artery (RCA). Vulnerable features, including thin-cap fibroatheroma (TCFA), lipid-rich plaque, macrophages, microvessels, and cholesterol crystals, were evaluated in each vessel. Vulnerable features in the LAD and non-LAD vessels were correlated at patient and plaque levels. RESULTS: At the patient level, vulnerable features in the LAD correlated with those in non-LAD vessels (TCFA p < 0.001; lipid-rich plaque p < 0.001; macrophages p = 0.010; microvessels p = 0.012; cholesterol crystals p = 0.045). However, an LAD-only strategy would have missed 30%-75% of patients with vulnerable features in non-LAD vessels; the adjusted miss rates were 58.7% for TCFA, 28.2% for lipid-rich plaque, 44.3% for macrophages, 36.9% for microvessels, and 75.7% for cholesterol crystals. At the plaque level, a similar number of high-risk plaques in non-LAD arteries would have been overlooked by the LAD-only approach, with the adjusted miss rates ranging from 74.3% for cholesterol crystals to 26.7% for lipid-rich plaque. CONCLUSIONS: Vulnerable plaque features in the LAD were associated with their presence in the other coronary arteries. However, a single-vessel LAD assessment would have missed a substantial proportion of patients with vulnerable features in the LCx or RCA.