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Aims This study was undertaken to assess the association between plaque features at culprit lesions assessed by frequency domain optical coherence tomography (FD-OCT) and impaired microvascular perfusion estimated by intracoronary electrocardiogram (IcECG) after elective percutaneous coronary intervention (PCI). Furthermore, we investigated whether IcECG could predict future cardiac events. Methods and results This study consisted of 84 patients who underwent both FD-OCT and IcECG during PCI. Patients were classified into two groups based on ST-segment elevation (ST-E) on IcECG after the procedure; ST-E (-) group (n= 53) and ST-E (+) group (n= 31). Minimum fibrous cap thickness was significantly thinner in the ST-E (+) group than in the ST-E (-) group (240 lm [IQR 180 to 310] vs. 100 lm [IQR 60 to 120], P < 0.001). Plaque rupture (7.5% vs. 35.5%, P= 0.001), lipid-rich plaque (75.5% vs. 100%, P< 0.001), the thin cap fibroatheroma (0% vs. 25.8%, P < 0.001) on pre- FD-OCT, protrusion (18.9% vs. 56.7%, P< 0.001), and intra-stent dissection (15.1% vs. 50.0%, P < 0.001) on post-FDOCT were significantly more frequently found in the ST-E (+) group than in the ST-E (-) group. The incidence of MACE (cardiac death, myocardial infarction, revascularization, hospitalization for heart failure) during 1-year was significantly higher in the ST-E (+) group than in the ST-E (-) group (5.7% vs. 19.4%, P<0.05). Conclusion Plaque features assessed by FD-OCT might be associated with impaired microvascular perfusion and ST-segment elevation on IcECG after the procedure could predict 1-year cardiac events after elective PCI. [ABSTRACT FROM AUTHOR]