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However, this two\u2010dimensional luminographic view cannot directly characterize plaque morphology or capture the spatial and temporal evolution of coronary thrombosis. We propose Spatial Culprit Mismatch (SCM) as a hypothesis\u2010generating framework describing selected cases in which the dominant angiographic obstruction is spatially separated from a more proximal plaque\u2010disruption phenotype identified by intracoronary imaging, especially with the use of optical coherence tomography (OCT). Potential mechanisms include longitudinal thrombus propagation, distal embolization, partial lysis, and repeated thrombosis and healing. SCM should not be inferred from angiography or OCT morphology alone; alternative embolic sources, multiple unstable plaques, and imaging limitations must be considered. Prospective studies are required to determine its prevalence, impact, and whether any SCM\u2010directed treatment improves outcomes<\/jats:p>","DOI":"10.1002\/ccd.70913","type":"journal-article","created":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T05:04:57Z","timestamp":1790571897000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Spatial Mismatch Between Angiographic Obstruction and Plaque Destabilization in Acute Coronary Syndromes: A Conceptual Narrative Review"],"prefix":"10.1002","author":[{"ORCID":"https:\/\/orcid.org\/0009-0009-5700-4372","authenticated-orcid":false,"given":"Fernando","family":"Quevedo\u2010Candela","sequence":"first","affiliation":[{"name":"Interventional Cardiology Division. 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