Background-Acute coronary occlusions leading to ST-segment elevation myocardial infarctions (STEMIs) are due primarily to rupture of atherosclerotic plaques. Present "vulnerable plaque" detection technology focuses on identifying individual plaques with no clear therapeutic plan beyond conventional risk factor reduction. We developed a spatial map of the distribution of acute coronary occlusions to test our hypothesis that plaque ruptures do not occur uniformly throughout the coronary tree. Methods and Results-We analyzed 208 consecutive patients who presented to the Brigham and Women's Hospital with STEMI and mapped the location of the acute coronary occlusion. These occlusions were not uniformly distributed throughout each of the major epicardial coronary arteries but tended to cluster within the proximal third of each of the vessels (right coronary artery, Pϭ0.001; left anterior descending artery, Pϭ0.003; left circumflex artery, Pϭ0.001). Furthermore, Poisson regression showed that for each 10-mm increase in distance from the ostium, the risk of an acute coronary occlusion was significantly decreased by 13% in the right coronary artery, 30% in the left anterior descending artery, and 26% in the left circumflex artery. Conclusions-Acute coronary occlusions leading to STEMI tend to cluster in predictable "hot spots" within the proximal third of the coronary arteries. Identification of these high-risk zones for acute coronary occlusions will lead to future advances in vulnerable plaque detection technology and potentially locally directed preventive strategies.