Vulnerable plaque detection: an unrealistic quest or a feasible objective with a clinical value?

Evidence from the first prospective studies of coronary atherosclerosis demonstrated that intravascular imaging has limited accuracy in detecting lesions that are likely to progress and cause future events, and divided the scientific community into experts who advocate abandoning this quest and others who suggest intensifying our efforts improve and optimise the available imaging techniques. Although the current evidence may not justify the use of invasive or non-invasive imaging in the clinical setting for the detection of vulnerable, high-risk lesions, it is apparent that imaging has provided unique insights about plaque pathophysiology and evolution. Recent evidence indicates that both invasive and non-invasive imaging also provides useful prognostic information in patients with established coronary artery disease and in asymptomatic individuals and is likely to enable more accurate risk stratification. Future studies are anticipated to provide further insights about the value of novel hybrid imaging techniques, which are expected to enable complete assessment of plaque pathophysiology, in detecting vulnerable lesions and identifying high-risk patients that would benefit from new aggressive treatments targeting coronary atherosclerosis.