High-risk plaques: intervene early or hold the line?

Plaque rupture with thrombosis is the predominant mechanism of acute coronary syndrome and sudden cardiac death, and a thin-capped fibroatheroma is the prototype of the rupture-prone plaque. A recent meta-analysis summarised the imaging features that characterise high-risk, rupture-prone plaques1. Findings were consistent across imaging modalities and clinical presentations, in studies with outcomes on both a patient and a lesion level, and including both invasive and non-invasive imaging: large plaque burden, small minimum lumen area (MLA), thin-cap fibroatheroma (TCFA), large lipid core burden index (LCBI) by near infrared spectroscopy (NIRS), low-attenuation plaque, positive remodelling, napkin ring sign, and spotty calcification. Plaques with more than one of these findings, especially using intravascular imaging, were most predictive of lesion-level events. However, the absolute event rate was low (median patient-level event rate of 4.2%), and most of the events associated were revascularisation and/or rehospitalisation with death or myocardial infarction (MI) representing the minority of events (approximately a 1% annual event rate). This is consistent with pathology studies indicating that the vast majority of plaque ruptures are silent and contribute to lesion progression rather...