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0 reviewsA misconception persisting among the scientifc and clinical Introductioncommunities relates to the correlation between arterial stenosis Limitations of historical and acute ischaemic events, including myocardial infarction and assessmentscerebral stroke. This Perspective article challenges the approach Pathophysiology of ischaemia and infarctionthat most of the current guidelines codify, which is based on the concept that occlusive arterial stenosis generally provokes ischaemic The degree of stenosis: a historical misstepevents. We highlight the mechanistic diferences between chronic Lack of correlation between or inducible ischaemia caused by fow-limiting stenoses and acute stenosis severity and thrombotic events and question the traditional reliance on stenosis ischaemic eventsgrading as a biomarker for therapeutic decision-making that many Management of plaques with guidelines enshrine. Furthermore, we review the latest evidence vulnerable characteristicshighlighting the lack of a correlation between stenosis severity and The role of advanced imaging the occurrence of acute thrombotic complications of atherosclerosis, technologiesin the light of a major clinical trial that included a large contemporary Beyond the misunderstanding: a shift in the clinical communitypopulation and showed that only one-third of major adverse cardiovascular events occur in individuals with obstructive coronary Conclusionsartery disease. These considerations aim to foster a shift, grounded in contemporary evidence, towards treatment approaches that address modifying plaque biology rather than stenoses per se, using pharmacological treatment as a fundamental factor in risk mitigation and moving away from sole reliance on stenosis grading as a primary determinant of therapeutic decisions.