Interventional cardiology has traditionally focused on fixing angiographic stenosis and documenting
ischaemia. Yet, most MI and sudden deaths arise from morphologically vulnerable but often non-flowlimiting
plaques. During the COVID-19 pandemic, this tension between “fixing the narrowing” and
truly preventing MI and death became starkly visible in daily practice. This paper explains the ethical,
clinical, and spiritual motivations behind our decision to prioritise vulnerability-guided complete
revascularization (VGCR) during the pandemic, despite controversy and systemic resistance, and
presents the outcomes of this approach. We describe a single-centre experience in which 1,750 elderly
COVID-19 patients with coronary artery disease and angiographically identified vulnerable plaques
(VPs) underwent VGCR between early 2020 and mid-2023, combined with a whole food plant-based
diet and comprehensive risk-factor optimisation. Despite advanced age and high baseline risk, zero
mortality was observed over three years of follow-up in this cohort. Rather than treating anatomy and
ischaemia in isolation, this approach targets the biological substrate of plaque rupture and erosion
while simultaneously modifying systemic drivers of vulnerability, such as inflammation, endothelial
dysfunction, and metabolic derangement. We argue that current guidelines, training pathways, and
ethical frameworks in interventional cardiology should evolve from a narrow focus on stenosis severity
and FFR towards a broader mandate: preventing MI and death by detecting and stabilising VPs as early
as possible, including during global crises such as COVID-19. Our experience suggests that VGCR,
when coupled with aggressive lifestyle and medical therapy, may offer a powerful—yet underused—
strategy to protect high-risk patients from fatal coronary events.
