In search of the "vulnerable plaque": can it be localized and will focal regional therapy ever be an option for cardiac prevention?

The search to find the location of future plaque ruptures or plaque erosions leading to myocardial infarction (so-called "vulnerable plaques") is an important area of cardiovascular research. Systemic therapy, including use of statins, targets the vulnerable patient. However, adverse events cannot be completely eliminated with the appropriate application of systemic therapies and thus has given rise to the possibility of local or regional therapy of "vulnerable plaques" to prevent future events. Until now, no criteria have been developed for consideration of this therapy. For such a strategy to work, there should be several prerequisites. These involve the identification of susceptible lesions, the number of lesions, their natural history, and proof that an interventional technique is preferable to medical therapy alone. The greatest deficiency relates to the fact that until the natural history of presumed "vulnerable plaques" is known one can never truly identify what constitutes a "vulnerable plaque." Much work needs to be done in this area, but ongoing and new trials should provide important information that could potentially change drastically how coronary artery disease is diagnosed and treated.