Coronary interventions - Mini focus on vulnerable plaques

Outcomes of non-ischaemic coronary lesions with high-risk plaque characteristics on coronary CT angiography

EuroIntervention 2023;18:1011-1021. DOI: 10.4244/EIJ-D-22-00562

Seokhun Yang
Seokhun Yang1, MD; Masahiro Hoshino2, MD; Taishi Yonetsu3, MD, PhD; Jinlong Zhang4, MD, PhD; Doyeon Hwang1, MD; Eun-Seok Shin5, MD, PhD; Joon-Hyung Doh6, MD, PhD; Chang-Wook Nam7, MD, PhD; Jianan Wang4, MD, PhD; Shaoliang Chen8, MD, PhD; Nobuhiro Tanaka9, MD, PhD; Hitoshi Matsuo10, MD, PhD; Takashi Kubo11, MD, PhD; Hyuk-Jae Chang12, MD, PhD; Tsunekazu Kakuta2, MD, PhD; Bon-Kwon Koo1,13, MD, PhD
1. Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea; 2. Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan; 3. Department of Interventional Cardiology, Tokyo Medical and Dental University, Tokyo, Japan; 4. Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang, China; 5. Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea and Division of Cardiology, Ulsan Hospital, Ulsan, Republic of Korea; 6. Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea; 7. Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea; 8. Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China; 9. Department of Cardiology, Tokyo Medical University, Tokyo, Japan; 10. Department of Cardiology, Gifu Heart Center, Gifu, Japan; 11. Wakayama Medical University, Wakayama, Japan; 12. Division of Cardiology, Severance Cardiovascular Hospital, Yonsei-Cedars-Sinai Integrative Cardiovascular Imaging Research Center, Yonsei University College of Medicine, Seoul, Republic of Korea; 13. Institute on Aging, Seoul National University, Seoul, Republic of Korea

Background: The integrative implications of quantitative and qualitative plaque characteristics on clinical outcomes and therapeutic guidance have not been fully investigated.

Aims: We aimed to investigate the combined prognostic value of quantitative and qualitative plaque measures and their interactions with treatment modalities and physiological lesion severity.

Methods: Among 697 vessels from 458 patients who underwent fractional flow reserve (FFR)-guided treatment, quantitative high-risk plaque (qn-HRP; plaque burden ≥70% and minimum lumen area <3.3 mm2) and qualitative HRP (ql-HRP; low-attenuation plaque or positive remodelling) were defined on coronary computed tomography angiography (CCTA). The primary endpoint was the vessel-oriented composite outcome (VOCO; a composite of cardiac death, myocardial infarction, or revascularisation).

Results: The mean baseline FFR was 0.85±0.12, and 25.8% underwent percutaneous coronary intervention (PCI) during the index procedure. In medically treated lesions, both qn-HRP and ql-HRP were associated with an increased risk of VOCO (p<0.05). Relative to the lesions with qn-HRP(-)/ql-HRP(-),those with qn-HRP(+)/ql-HRP(+) showed a higher risk of VOCO (hazard ratio [HR] 8.36, 95% confidence interval [CI]: 2.86–24.44). The PCI group showed a lower risk for VOCO than the medical treatment group (HR 0.31, 95% CI: 0.11–0.91) in lesions with qn-HRP(+)/ql-HRP(+). This difference was consistent in lesions with an FFR of 0.81–0.90 (HR 0.19, 95 CI: 0.04–0.90), but not in those with an FFR of>0.90.

Conclusions: In non-ischaemic lesions, ql-HRP and qn-HRP showed a synergistic impact on risk assessment and had prognostic interactions with FFR and treatment modalities. Therefore, they need to be integrated into risk stratification and the optimisation of a treatment strategy. NCT04037163. 

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coronary artery diseasefractional flow reservenon-invasive imaging
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