Biomechanical determinants of plaque erosion: translational implications and precision care

Abstract

Plaque erosion is a major cause of acute coronary syndromes and is characterized by endothelial denudation, fibrous-cap integrity, and platelet-rich thrombosis. Advances in intracoronary optical coherence tomography (OCT) have enabled in vivo identification of erosion, revealing unique clinical profiles and therapeutic opportunities, including selectively avoiding stents. Increasing evidence implicates local mechanical forces, particularly spatially heterogeneous shear stress, as central drivers of endothelial injury in erosion. Computational biomechanics, including fluid dynamics and emerging OCT-based finite element analysis, allow detailed quantification of hemodynamic and structural stresses at plaque surfaces. These models provide mechanistic insight into how flow disturbance, plaque geometry, and wall stress converge to trigger erosion. Integrating biomechanical signatures with erosion-associated biological pathways and clinical imaging may refine risk stratification, guide conservative management, and identify new therapeutic targets. This review summarizes the current understanding of biomechanical forces at sites of plaque erosion, and outlines priorities for translating biomechanics into precision cardiovascular care.