Highlights • This is the first study on plasma ceramides associated with plaque rupture (PR) evaluated by optical coherence tomography (OCT). • Elevated ceramide levels are independent predictors for PR in ST-segment elevation myocardial infarction (STEMI) patients. • Distinguishing PR from plaque erosion (PE) has important clinical implications. • Elevated ceramides may have a pathogenic link with occurrence of PR. Abstract Background and aims Ceramides (Cer) are an atherogenic substance.