Reviewing imaging modalities for the assessment of plaque erosion


      • Plaque erosion whose hallmark is thrombus formation without cap disruption.
      • Optical coherence tomography (OCT) facilitated plaque erosion detection.
      • CCTA is the sole non-invasive technique for coronary plaque evaluation.


      Plaque rupture followed by intracoronary thrombus formation is recognized as the most common pathophysiological mechanism in acute coronary syndromes (ACS). The second most common underlying substrate for ACS is plaque erosion whose hallmark is thrombus formation without cap disruption. Invasive and non-invasive methods have emerged as a promising tool for evaluation of plaque features that either predict or detect plaque erosion. Optical coherence tomography (OCT), high-definition intravascular ultrasound (IVUS), near-infrared spectroscopy (NIRS), and near-infrared autofluorescence (NIRF) have been used to study plaque erosion. The detection of plaque erosion in the clinical setting, mainly facilitated by OCT, has shed light upon the complex pathophysiology underlying ACS not related to plaque rupture. Coronary computed tomography angiography (CCTA), which is to date the most commonly used non-invasive technique for coronary plaque evaluation, may also have a role in the evaluation of patients predisposed to erosion. Also, computational models enabling quantification of endothelial shear stress may pave the way to new research in coronary plaque pathophysiology. This review focuses on the recent imaging techniques for the evaluation of plaque erosion including invasive and non-invasive assessment.

      Graphical abstract


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Atherosclerosis
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Libby P.
        • Pasterkamp G.
        • Crea F.
        • et al.
        Reassessing the mechanisms of acute coronary syndromes.
        Circ. Res. 2019; 124: 150-160
        • Yonetsu T.
        • Kakuta T.
        • Lee T.
        • et al.
        In vivo critical fibrous cap thickness for rupture-prone coronary plaques assessed by optical coherence tomography.
        Eur. Heart J. 2011; 32: 1251-1259
        • Tian J.
        • Ren X.
        • Vergallo R.
        • et al.
        Distinct morphological features of ruptured culprit plaque for acute coronary events compared to those with silent rupture and thin-cap fibroatheroma: a combined optical coherence tomography and intravascular ultrasound study.
        J. Am. Coll. Cardiol. 2014; 63: 2209-2216
        • Jia H.
        • Abtahian F.
        • Aguirre A.D.
        • et al.
        In vivo diagnosis of plaque erosion and calcified nodule in patients with acute coronary syndrome by intravascular optical coherence tomography.
        J. Am. Coll. Cardiol. 2013; 62: 1748-1758
        • Bourantas C.V.
        • Jaffer F.A.
        • Gijsen F.J.
        • et al.
        Hybrid intravascular imaging: recent advances, technical considerations, and current applications in the study of plaque pathophysiology.
        Eur. Heart J. 2017; 38: 400-412
        • Maehara A.
        • Matsumura M.
        • Ali Z.A.
        • et al.
        IVUS-guided versus OCT-guided coronary stent implantation: a critical appraisal, JACC.
        Cardiovascular imaging. 2017; 10: 1487-1503
        • Virmani R.
        • Burke A.P.
        • Farb A.
        • et al.
        Pathology of the vulnerable plaque.
        J. Am. Coll. Cardiol. 2006; 47: C13-C18
        • Jinnouchi H.
        • Virmani R.
        • Finn A.V.
        Are characteristics of plaque erosion defined by optical coherence tomography similar to true erosion in pathology?.
        Eur. Heart J. 2018; 39: 2086-2089
        • Sinclair H.
        • Bourantas C.
        • Bagnall A.
        • et al.
        OCT for the identification of vulnerable plaque in acute coronary syndrome.
        JACC. Cardiovascular imaging. 2015; 8: 198-209
        • Dai J.
        • Xing L.
        • Jia H.
        • et al.
        In vivo predictors of plaque erosion in patients with ST-segment elevation myocardial infarction: a clinical, angiographical, and intravascular optical coherence tomography study.
        Eur. Heart J. 2018; 39: 2077-2085
        • Jia H.
        • Dai J.
        • Hou J.
        • et al.
        Effective anti-thrombotic therapy without stenting: intravascular optical coherence tomography-based management in plaque erosion (the EROSION study).
        Eur. Heart J. 2017; 38: 792-800
        • Xing L.
        • Yamamoto E.
        • Sugiyama T.
        • et al.
        EROSION study (effective anti-thrombotic therapy without stenting: intravascular optical coherence tomography-based management in plaque erosion): a 1-year follow-up report.
        Circulation. Cardiovascular interventions. 2017; 10
        • Cuesta J.
        • Antuña P.
        • Jiménez C.
        • et al.
        Can plaque erosion Be visualized by high-definition intravascular ultrasound?.
        JACC Cardiovasc. Interv. 2020; 13: e57-e61
        • Higuma T.
        • Soeda T.
        • Abe N.
        • et al.
        A combined optical coherence tomography and intravascular ultrasound study on plaque rupture, plaque erosion, and calcified nodule in patients with ST-segment elevation myocardial infarction: incidence, morphologic characteristics, and outcomes after percutaneous coronary intervention.
        JACC Cardiovasc. Interv. 2015; 8: 1166-1176
        • Kwon J.E.
        • Lee W.S.
        • Mintz G.S.
        • et al.
        Multimodality intravascular imaging assessment of plaque erosion versus plaque rupture in patients with acute coronary syndrome.
        Korean Circ J. 2016; 46: 499-506
        • Kilic I.D.
        • Caiazzo G.
        • Fabris E.
        • et al.
        Near-infrared spectroscopy-intravascular ultrasound: scientific basis and clinical applications.
        Eur Heart J Cardiovasc Imaging. 2015; 16: 1299-1306
        • Waksman R.
        • Di Mario C.
        • Torguson R.
        • et al.
        Identification of patients and plaques vulnerable to future coronary events with near-infrared spectroscopy intravascular ultrasound imaging: a prospective, cohort study.
        Lancet (London, England). 2019; 394: 1629-1637
        • Yamaguchi M.
        • Sugiyama T.
        • Hoshino M.
        • et al.
        Two distinct phenotypes of plaque erosion assessed by multimodality intracoronary imaging: a case series.
        Eur Heart J Case Rep. 2020; 4: 1-5
        • Stein-Merlob A.F.
        • Hara T.
        • McCarthy J.R.
        • et al.
        Atheroma susceptible to thrombosis exhibit impaired endothelial permeability in vivo as assessed by nanoparticle-based fluorescence molecular imaging.
        Circulation. Cardiovascular imaging. 2017; 10
        • Knuuti J.
        • Wijns W.
        • Saraste A.
        • et al.
        2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: the Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC).
        Eur. Heart J. 2019;
        • Conte E.
        • Mushtaq S.
        • Pontone G.
        • et al.
        Plaque quantification by coronary computed tomography angiography using intravascular ultrasound as a reference standard: a comparison between standard and last generation computed tomography scanners.
        Eur Heart J Cardiovasc Imaging. 2020; 21: 191-201
        • Fischer C.
        • Hulten E.
        • Belur P.
        • et al.
        Coronary CT angiography versus intravascular ultrasound for estimation of coronary stenosis and atherosclerotic plaque burden: a meta-analysis.
        J Cardiovasc Comput Tomogr. 2013; 7: 256-266
        • Voros S.
        • Rinehart S.
        • Qian Z.
        • et al.
        Coronary atherosclerosis imaging by coronary CT angiography: current status, correlation with intravascular interrogation and meta-analysis.
        JACC. Cardiovascular imaging. 2011; 4: 537-548
        • Adamson P.D.
        • Dweck M.R.
        • Newby D.E.
        The vulnerable atherosclerotic plaque: in vivo identification and potential therapeutic avenues.
        Heart. 2015; 101: 1755-1766
        • Conte E.
        • Annoni A.
        • Pontone G.
        • et al.
        Evaluation of coronary plaque characteristics with coronary computed tomography angiography in patients with non-obstructive coronary artery disease: a long-term follow-up study.
        Eur Heart J Cardiovasc Imaging. 2017; 18: 1170-1178
        • Motoyama S.
        • Ito H.
        • Sarai M.
        • et al.
        Plaque characterization by coronary computed tomography angiography and the likelihood of acute coronary events in mid-term follow-up.
        J. Am. Coll. Cardiol. 2015; 66: 337-346
        • Adamson P.D.
        • Williams M.C.
        • Dweck M.R.
        • et al.
        Guiding therapy by coronary CT angiography improves outcomes in patients with stable chest pain.
        J. Am. Coll. Cardiol. 2019; 74: 2058-2070
        • Erbel R.
        • Möhlenkamp S.
        • Moebus S.
        • et al.
        Coronary risk stratification, discrimination, and reclassification improvement based on quantification of subclinical coronary atherosclerosis: the Heinz Nixdorf Recall study.
        J. Am. Coll. Cardiol. 2010; 56: 1397-1406
        • Kashiwagi M.
        • Tanaka A.
        • Kitabata H.
        • et al.
        Feasibility of noninvasive assessment of thin-cap fibroatheroma by multidetector computed tomography.
        JACC. Cardiovascular imaging. 2009; 2: 1412-1419
        • Motoyama S.
        • Sarai M.
        • Harigaya H.
        • et al.
        Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute coronary syndrome.
        J. Am. Coll. Cardiol. 2009; 54: 49-57
        • Ozaki Y.
        • Okumura M.
        • Ismail T.F.
        • et al.
        Coronary CT angiographic characteristics of culprit lesions in acute coronary syndromes not related to plaque rupture as defined by optical coherence tomography and angioscopy.
        Eur. Heart J. 2011; 32: 2814-2823
        • van den Hoogen I.J.
        • Gianni U.
        • Al Hussein Alawamlh O.
        • et al.
        What atherosclerosis findings can CT see in sudden coronary death: plaque rupture versus plaque erosion.
        J Cardiovasc Comput Tomogr. 2020; 14: 214-218
        • Opolski M.P.
        • Debski A.
        • Petryka J.
        • et al.
        CT for prediction of plaque erosion resulting in myocardial infarction with non-obstructive coronary arteries.
        J Cardiovasc Comput Tomogr. 2017; 11: 237-239
        • Andreini D.
        • Pontone G.
        • Mushtaq S.
        • et al.
        Long-term prognostic impact of CT-leaman score in patients with non-obstructive CAD: results from the COronary CT angiography EvaluatioN for clinical outcomes InteRnational multicenter (CONFIRM) study.
        Int. J. Cardiol. 2017; 231: 18-25
        • Lee S.E.
        • Sung J.M.
        • Andreini D.
        • et al.
        Differences in progression to obstructive lesions per high-risk plaque features and plaque volumes with CCTA, JACC.
        Cardiovascular imaging. 2020; 13: 1409-1417
        • Ahmadi A.
        • Argulian E.
        • Leipsic J.
        • et al.
        From subclinical atherosclerosis to plaque progression and acute coronary events: JACC state-of-the-art review.
        J. Am. Coll. Cardiol. 2019; 74: 1608-1617
        • Yamamoto E.
        • Thondapu V.
        • Poon E.
        • et al.
        Endothelial shear stress and plaque erosion: a computational fluid dynamics and optical coherence tomography study.
        JACC. Cardiovascular imaging. 2019; 12: 374-375
        • Stone P.H.
        • Maehara A.
        • Coskun A.U.
        • et al.
        Role of low endothelial shear stress and plaque characteristics in the prediction of nonculprit major adverse cardiac events: the PROSPECT study.
        JACC. Cardiovascular imaging. 2018; 11: 462-471
        • Samady H.
        • Molony D.S.
        • Coskun A.U.
        • et al.
        Risk stratification of coronary plaques using physiologic characteristics by CCTA: focus on shear stress.
        J Cardiovasc Comput Tomogr. 2019;
        • Park J.B.
        • Choi G.
        • Chun E.J.
        • et al.
        Computational fluid dynamic measures of wall shear stress are related to coronary lesion characteristics.
        Heart. 2016; 102: 1655-1661
        • Lee J.M.
        • Choi G.
        • Koo B.K.
        • et al.
        Identification of High-Risk Plaques Destined to Cause Acute Coronary Syndrome Using Coronary Computed Tomographic Angiography and Computational Fluid Dynamics.
        JACC, 2018 (Cardiovascular imaging)
        • Han D.
        • Starikov A.
        • Óh B.
        • et al.
        Relationship between endothelial wall shear stress and high-risk atherosclerotic plaque characteristics for identification of coronary lesions that cause ischemia: a direct comparison with fractional flow reserve.
        Journal of the American Heart Association. 2016; 5
        • Costopoulos C.
        • Timmins L.H.
        • Huang Y.
        • et al.
        Impact of combined plaque structural stress and wall shear stress on coronary plaque progression, regression, and changes in composition.
        Eur. Heart J. 2019; 40: 1411-1422
        • Hoshi T.
        • Sato A.
        • Akiyama D.
        • et al.
        Coronary high-intensity plaque on T1-weighted magnetic resonance imaging and its association with myocardial injury after percutaneous coronary intervention.
        Eur. Heart J. 2015; 36: 1913-1922
        • Henein M.Y.
        • Vancheri S.
        • Bajraktari G.
        • et al.
        Coronary Atherosclerosis Imaging, Diagnostics (Basel). vol. 10. 2020
        • Kato S.
        • Kitagawa K.
        • Ishida N.
        • et al.
        Assessment of coronary artery disease using magnetic resonance coronary angiography: a national multicenter trial.
        J. Am. Coll. Cardiol. 2010; 56: 983-991
        • Kolossváry M.
        • Park J.
        • Bang J.I.
        • et al.
        Identification of invasive and radionuclide imaging markers of coronary plaque vulnerability using radiomic analysis of coronary computed tomography angiography.
        Eur Heart J Cardiovasc Imaging. 2019; 20: 1250-1258