In this JACC Deep Dive, Harlan M. Krumholz, MD, SM, FACC reviews a study by Covani, et al that uses OCT imaging in over 1,500 ACS patients to show how increasing cardiovascular risk factor burden—like smoking, diabetes, and hypertension—is strongly associated with vulnerable plaque features such as thin caps, inflammation, and rupture. The findings were most pronounced in STEMI patients and reinforce the biological impact of cumulative risk. Reviewers found the core results intuitive but pushed for deeper mechanistic insights, leading to a stronger final paper with improved clarity, additional analyses, and a more nuanced understanding of how traditional risk factors shape plaque instability.