Letter: Non-culprit plaque rupture in STEMI – marker of vulnerability or actionable risk?

I read with great interest the study by Zhao et al, evaluating the prognostic implications of non-culprit plaque rupture and thin-cap fibroatheroma (TCFA) assessed by three-vessel optical coherence tomography (OCT) in patients with ST-segment elevation myocardial infarction (STEMI).1 The authors should be congratulated for assembling a large imaging cohort with extended follow-up and for addressing the clinically important concept of pancoronary vulnerability. Nonetheless, several clinical and practical considerations deserve emphasis.

First, the discordance between patient-level and lesion-level associations of plaque rupture with outcomes highlights the persistent challenge of attributing future events to specific non-culprit plaques. Previous prospective imaging studies, including PROSPECT and its successor investigations, have shown that although vulnerable plaques are common, only a minority of them lead to clinical events, suggesting that plaque morphology alone has limited predictive value at the lesion level.23 This uncertainty may explain the wide confidence intervals observed in the current study.

In addition, the finding that TCFA – but not rupture – predicts outcomes should be interpreted cautiously. OCT-defined TCFA represents a structural surrogate rather than a direct measure of biological instability....