Preventive PCI Benefit May Depend on Lipid Richness of Coronary Plaques: Study
South Korea: A post hoc analysis of the PREVENT trial suggested that the benefit of preventive percutaneous coronary intervention (PCI) may be concentrated among patients with lipid-rich coronary plaques. Published in Circulation, the findings highlight plaque characteristics as a potential factor in identifying patients who may benefit most from preventive PCI.
Preventive PCI has been investigated as a strategy for treating coronary plaques that do not significantly restrict blood flow but have features associated with a higher risk of future cardiac events. However, determining which vulnerable plaques are most likely to benefit from intervention remains challenging, particularly when decisions are based primarily on plaque size or the degree of narrowing.
Seong-Bong Wee, MD, Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea, and colleagues conducted a post hoc analysis of the PREVENT trial to assess whether the lipid content of coronary plaques could help identify patients who may benefit from preventive PCI. The PREVENT trial enrolled 1,606 patients between September 2015 and September 2021.
The current analysis included 598 patients with 632 coronary lesions. Participants had plaques with a burden greater than 70% and a minimal lumen area below 4 mm² on intravascular ultrasound, while also undergoing near-infrared spectroscopy assessment. The mean participant age was 64.1 years, and 27.9% were women.
Researchers defined a lipid-rich plaque (LRP) as having a maximum lipid core burden index exceeding 315 over a 4-mm segment. Patients were followed for a median of 5.6 years, with the primary outcome comprising cardiac death, target-vessel myocardial infarction, ischemia-driven target-vessel revascularization, or hospitalization for unstable or progressive angina.
The analysis revealed:
- Lipid-rich plaques were identified in 223 patients, representing 37.3% of the study population, involving 234 lesions.
- Patients with LRPs experienced the primary composite outcome more frequently than those without LRPs, at 12.5% versus 4.7%, respectively.
- Among patients with LRPs, preventive PCI was associated with a substantially lower risk of the primary outcome compared with optimal medical therapy alone, occurring in 7.3% versus 17.6% of patients.
- In contrast, preventive PCI did not reduce the primary outcome among patients without LRPs, with events occurring in 5.5% of the PCI group versus 4.2% of those receiving medical therapy alone.
- A significant interaction between treatment strategy and LRP status indicated that plaque composition influenced the apparent benefit of preventive PCI.
The findings suggest that plaque composition may provide important information beyond conventional measures of plaque burden and lumen size when considering preventive coronary intervention. Although large plaques with a small lumen area may appear anatomically severe, the absence of lipid-rich characteristics may identify lesions less likely to benefit from PCI.
The authors concluded that preventive PCI was associated with fewer major cardiac events among patients with near-infrared spectroscopy-defined lipid-rich plaques, whereas no significant benefit was observed in patients with non-lipid-rich plaques. As the analysis was post hoc, the findings require confirmation in prospective studies before lipid-rich plaque assessment can be routinely used to guide preventive PCI decisions.
Reference: https://doi.org/10.1161/CIRCULATIONAHA.126.080384
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