Two recent papers published in Heart have evaluated the utility of advanced imaging modalities for the morphological detection and evaluation of high-risk atherosclerotic plaques.1 ,2 While these studies employed differing methodologies (CT angiography (CTA), optical coherence tomography (OCT) and optic angioscopy), the results are broadly concordant and of major potential clinical significance. Notably, when subjected to percutaneous coronary intervention (PCI), such high-risk plaques may embolise and release a slurry of lipid-rich necrotic debris to the distal circulation, with consequent myocardial damage. In addition, it has been proposed that PCI of lipid-rich plaques (LRP) with thin fibrous caps (<65 μm; thin-cap fibroatheroma (TCFA)) may be associated with lipid embolisation. However, since stable angina patients do not require urgent intervention, detailed assessment of target lesions may be feasible for the recognition and assessment of LRP before elective PCI.

Radiofrequency intravascular ultrasound (RF-IVUS) analysis is useful in defining the distribution, severity and composition of atherosclerotic plaques. Although RF-IVUS lacks the spatial resolution to directly measure fibrous cap thickness, it has been proposed that a necrotic core without overlying fibrous tissue (necrotic core abutting lumen) may represent TCFA. The presence …