Abstract
BACKGROUND: Polyvascular disease (PVD), defined as atherosclerosis involving ≥ 2 vascular beds, confers poor clinical outcome but lacks early noninvasive predictors. This study combined multimodal imaging to explore the retinal vessel characteristics and coronary plaque morphology in patients with PVD. METHODS: A total of 311 acute coronary syndrome(ACS) patients who underwent coronary angiography(CAG) with optical coherence tomography(OCT) undertook non-contrast enhanced magnetic resonance angiography(NCE-MRA). Optical coherence tomography angiography(OCTA) was performed on 177 patients among them. Finally 238 patients entered OCT analyses, whereas 172 entered OCTA analyses. RESULTS: OCT cohort included 199 PVD patients and 39 non- PVD patients. Compared with non-PVD group, the PVD group had older patients (60.17 ± 8.90 vs. 52.10 ± 11.73, p < 0.001), a lower proportion of men (68.3% vs. 84.6%, p = 0.041), and a higher percentage of patients with diabetes (35.2% vs. 17.9%, p = 0.035). OCT analyses showed culprit plaque of PVD group were more likely to be calcified plaques (13.6% vs. 0%, *p*< 0.05) and had a higher proportion of nodular calcifications (40.7% vs. 17.9%, p = 0.007). OCTA cohort consisted of 137 PVD patients and 35 non- PVD patients. OCTA analyses demonstrated significantly reduced vessel density across all 3 retinal capillary plexuses in PVD group. Multivariate analyses showed that vessel density of full retina fovea was independently predictive of PVD(OR: 0.883, 95% CI: 0.807–0.966, p = 0.007). ROC analysis demonstrated that full retinal vascular density fovea alone yielded an AUC of 0.667 (95% CI: 0.577–0.7556) for predicting PVD. CONCLUSION: Full retinal vessel density can serve as a non-invasive predictor for PVD. CLINICAL TRIAL REGISTRATION: NCT06016608. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12872-026-05650-x.