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Intravascular optical coherence tomography (OCT) is increasingly being used to assess coronary vessel pathology in vivo due to its unrivalled high resolution of 10–20 µm. Previous reports have shown that OCT is capable of visualizing thin-cap fibroatheromas (TCFAs),1 which are thought to be the precursor lesions of ruptured plaques responsible for the majority of thrombosis-mediated sudden death.2 In addition, OCT is able to identify features that have been related to the advancement of atherosclerotic lesions, including neovascularization3,4 and macrophage infiltration.5,6 It is against this background that Uemura and colleagues describe the baseline OCT morphological characteristics of angiographically non-significant, non-culprit coronary lesions exhibiting rapid progression over a period of 6–9 months.7 At a median follow-up of 7 months, 13 (19%) of the 69 studied lesions showed angiographic progression from a mean diameter stenosis of 28.8–61.4%, compared with 28.9–29.3% in the remaining lesions. Progression was clinically silent in all but three patients. OCT at baseline suggested a higher incidence of TCFAs, intraplaque microchannels, lipid pools, macrophages, intimal lacerations, and intraluminal thrombi in the progressed lesions, thus being in line with pathology-driven hypotheses of the role of these features in the progression of coronary atherosclerosis.7The study is intriguing in that it reports for the first time the innovative concept of using OCT to evaluate potential markers of rapid plaque progression. Nevertheless, the results should be interpreted with caution: first due to the small size and possible selection bias in the evaluated cohort; and secondly, in view of the current methodological concepts. Concerning the former, lesions were selected from the angiogram by the identification of a focal discrete non-significant stenosis (<50% diameter stenosis), thus disregarding important information about the plaque (total burden) at baseline, as this can be visualized neither by the angiographic …

In search of vulnerable features of coronary plaques with optical coherence tomography: is it time to rethink the current methodological concepts?