What are the PROSPECTs and clinical implications of vulnerable plaque?

This editorial refers to 'Thin-cap fibroatheroma predicts clinical events in diabetic patients with normal fractional flow reserve: the COMBINE OCT-FFR trial', by E. Kehdi et al., https://doi.org/10.1093/eurheartj/ehab433. Despite the fact that it has been three decades since James Muller and his colleagues first proposed the concept of vulnerable plaque1 and 18 years since Naghavi et al. published their consensus document summarizing the concepts behind vulnerable patients and vulnerable plaques, including classifications for clinical and pathological evaluation,2,3 we still have much to learn about the clinical implications of vulnerable plaque (Graphical Abstract). Feasibility of vulnerable plaque detection in clinical practice was the initial clinical hurdle. In 2011, the first landmark natural history study of rupture-prone vulnerable plaques, PROSPECT, used three-vessel virtual histology–intravascular ultrasound to study patients presenting with an acute coronary syndrome.4 After PROSPECT, there remained a gap in major natural history...