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Objective To investigate the expression levels of small dense low-density lipoprotein cholesterol (sdLDLC), serum amyloid A (SAA), and platelet-activating factor (PAF) in acute coronary syndrome (ACS) and their relationship with vulnerable plaques. Methods A total of 136 patients with coronary heart disease were divided into stable angina pectoris (SAP) group (n=45) and ACS group (n=91) . Based on plaque stability, they were further divided into stable plaque group (n=53) and vulnerable plaque group (n=83) . Differences in sdLDLC, SAA, PAF levels, and plaque characteristics were measured. Results Compared with the SAP group, the ACS group had a higher proportion of male gender, smoking history, levels of white blood cell (WBC), triglyceride (TG), uric acid, creatinine, sdLDLC, SAA, and PAF, and lower level of HDL-C (P＜0.05) . The ACS group showed significantly larger necrotic core (NC), lipid pool area (LPA), plaque lipid ratio (PLR), eccentric index (EI), remodeling index (RI), plaque burden (PB) compared to the SAP group (P＜0.05) . There were statistically significant differences in the expression levels of sdLDLC, SAA, and PAF between the stable plaque group and the vulnerable plaque group (P＜0.05) . Pearson correlation analysis showed that sdLDLC, SAA, and PAF were positively correlated with NT, LPA, PLR, EI, RI, PB (P＜0.05) . Multivariate logistic regression analysis revealed that sdLDLC, SAA, and PAF were independent predictors of vulnerable plaques (P＜0.05) .Conclusion Levels of sdLDLC, SAA, and PAF are significantly elevated in ACS patients and are closely related to vulnerable plaques. [ABSTRACT FROM AUTHOR]