Letter: Identifying vulnerable coronary atherosclerotic plaques: from theory to practice

We read with great interest the study by del Val et al1 regarding the prognostic role of vulnerable plaque features in non-ischaemic lesions, showing thin-cap fibroatheroma (TCFA) as the strongest predictor of future events, with the addition of other vulnerable plaque parameters further increasing this risk. This study is of particular importance; however, several key insights must be highlighted.

Firstly, 68.4-84.4% of patients received statins, with significantly lower use in most subgroups with high-risk characteristics, compared to patients without. Furthermore, there is no report of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor use. It is well documented that PCSK9 inhibitors lead to plaque regression and stabilisation2. Notably, a phenotype of “triple regression” − which consists of the combined presence of (a) percentage of atheroma volume reduction, (b) maximum lipid core burden index within 4 mm reduction and (c) minimal fibrous cap thickness increase − is significantly associated with fewer adverse outcomes and independently associated with the use of PCSK9 inhibitors3. Given the prognostic significance of both vulnerable plaques and the presence of plaque regression, as well as the...