Correlation between polyvascular atherosclerotic burden and coronary complexity in acute coronary syndromes

Introduction Atherosclerosis is a systemic disease affecting multiple arterial territories, and extracoronary involvement reflects a higher global atherosclerotic burden and worse cardiovascular prognosis. However, its association with coronary anatomical complexity has not been fully established. The aim of this study was to evaluate the correlation between peripheral atherosclerotic plaques detected by vascular Doppler ultrasound and coronary disease complexity in patients presenting with acute coronary syndromes (ACS). Methods This was a prospective, single-centre observational study including consecutive patients admitted with ACS between January 2023 and February 2026. The presence of peripheral atherosclerotic plaques was assessed using vascular Doppler ultrasound in four arterial territories (right and left carotid and femoral arteries), generating a score ranging from 0 to 4 according to the number of affected territories. Coronary complexity was determined using the SYNTAX score and the number of major epicardial coronary vessels with ≥50% stenosis. Spearman’s correlation and linear regression analyses were performed to assess the association between peripheral atherosclerotic burden and coronary disease. In addition, the SYNTAX score was compared across categories of peripheral burden (low: 0–1; moderate: 2; high: 3–4 territories), defined according to a stratification analogous to that employed in the PESA study. Results A total of 315 patients with ACS were included. Baseline characteristics are presented in Table 1. Coronary angiography was performed in 95% (n=300), and the SYNTAX score was available in 74.6% (n=235). Vascular Doppler ultrasound was performed in 93.7% (n=295) of the cohort. A positive correlation was observed between the number of affected peripheral territories and the SYNTAX score (ρ=0.18; p<0.01) (Figure 1A). In linear regression analysis, each additional affected territory was associated with a mean increase of 1.04 points in the SYNTAX score (β=1.04; 95% CI 0.27–1.81; p=0.008). The number of affected peripheral territories was also correlated with greater coronary disease extent, as assessed by the number of diseased epicardial vessels (ρ=0.31; p<0.01) (Figure 1B). A progressive increase in SYNTAX score was observed across categories of peripheral atherosclerotic burden (p=0.035) (Figure 1C). In sex-stratified analysis, no significant interaction was observed (p=0.083). Conclusions In patients presenting with ACS, peripheral atherosclerotic burden was significantly associated with greater coronary anatomical complexity and extent of disease, demonstrating a progressive relationship between systemic vascular involvement and coronary burden. These findings suggest that peripheral vascular assessment may provide additional information for anatomical risk stratification.Baseline characteristics