In previous analyses using finite element model analysis, circumferential stress was reduced by the inclusion of a calcium deposit in a representative human anatomical configuration. However, a recent report, also using finite element analysis, suggests that microscopic calcium deposits increase plaque stress. We used mathematical models to predict the effects of rigid and liquid inclusions (modeling a calcium deposit and a lipid necrotic core, respectively) in a distensible material (artery wall) on mechanical failure under uniaxial and biaxial loading in a range of configurations. Without inclusions, stress levels were low and uniform. In the analytical model, peak stresses were elevated at the edges of a rigid inclusion. In the finite element model, peak stresses were elevated at the edges of both inclusions, with minimal sensitivity to the wall distensibility and the size and shape of the inclusion. Presence of both a rigid and a soft inclusion enlarged the region of increased wall stress compared with either alone. In some configurations, the rigid inclusion reduced peak stress at the edge of the soft inclusion but simultaneously increased peak stress at the edge of the rigid inclusion and increased the size of the region affected. These findings suggest that the presence of a calcium deposit creates local increases in failure stress, and, depending on relative position to any neighboring lipid pools, it may increase peak stress and the plaque area at risk of mechanical failure. plaque rupture; vulnerable plaque; atherosclerosis; vascular calcification CALCIUM DEPOSITS, WHICH OCCUR commonly in atherosclerotic plaque, introduce mechanical discontinuities with compliance mismatch where they interface with the surrounding distensible tissue. Mechanical vulnerability is a central determinant of myocardial infarction and other acute coronary syndromes (14), and it has been shown to increase when the plaque has a lipid pool under a thin cap (23,31). Some recent evidence points to calcium deposits as also playing a role in mechanical vulnerability. In balloon angioplasty imaged dynamically by intravascular ultrasound, plaque failure is seen to occur along the edge of calcium deposits (15). On the basis of computed tomographic scanning of coronary arteries, the severity of calcification in coronary arteries correlates with cardiovascular events (1) at least as well as, and possibly better than, conventional risk factor analysis (28). Extensive histopathological analyses performed by investigators at the Armed Forces Institute of Pathology have suggested that calcification may contribute, in part, to human plaque rupture (6). On the basis of intravascular ultrasonic images, patients with stable angina have greater circumferential arcs of coronary calcification than patients with unstable angina (3). Also using intravascular ultrasound, Ehara et al. (12,13) found that patients with stable angina have fewer, larger contiguous deposits, whereas patients with acute coronary syndromes have many more and smaller deposits,...