Background: Cardiovascular risk factors are strongly associated with adverse clinical outcomes, including acute coronary syndromes (ACS). While individual risk factors have been related to specific plaque phenotypes, the relationship between the cumulative number of risk factors and plaque vulnerability has not been systematically explored.
Objectives: To investigate the association between the number of cardiovascular risk factors and plaque vulnerability defined by optical coherence tomography (OCT).
Methods: Patients with ACS were divided into five groups based on their number of traditional risk factors (diabetes, hypertension, hyperlipidemia, smoking) or into two groups (0-1 vs. ≥ 2 risk factors). Features of vulnerability in both culprit and non-culprit lesions were analyzed.
Results: A total of 2187 plaques (1581 culprit and 606 non-culprit plaques) were analyzed. In culprit plaques, the prevalence of lipid-rich plaques (p-trend = 0.027), thin-cap fibroatheromas (TCFA) (p-trend = 0.006), macrophages (p-trend < 0.001), microvessels (p-trend < 0.001), and cholesterol crystals (p-trend = 0.032) increased as the number of risk factors increased. The presence of two or more risk factors was independently associated with all vulnerable features except lipid-rich plaques. Plaque rupture showed an increasing prevalence as the number of risk factors increased (p-trend = 0.015) while plaque erosion showed a decreasing trend (p-trend < 0.001). In non-culprit plaques, only macrophages, cholesterol crystals, and the cumulative number of vulnerable features in each plaque exhibited a significant positive association with the number of risk factors.
Conclusions: In patients with ACS, an increasing number of cardiovascular risk factors was strongly associated with greater plaque vulnerability, especially at culprit lesions. These findings may explain the relationship between traditional risk factors and adverse clinical outcomes.
Editors
Editor-in-Chief
Harlan M. Krumholz, MD, SM, FACC
CME Editor
Ragavendra R. Baliga, MD
Author
Ioannis Dimarakis, MD
Important Dates
Date of Release: July 7, 2025
Term of Approval/Date of CME/MOC Expiration: July 6, 2026