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Residual plaque burden in patients with acute coronary syndromes after successful percutaneous coronary intervention
John A McPherson1, Akiko Maehara, Giora Weisz
1Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Insights
Untreated atherosclerotic disease, particularly high-plaque burden lesions (PB70), remains common after percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS). These PB70 lesions significantly increase the risk of major adverse cardiovascular events (MACE).
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Imaging
Background:
- Residual atherosclerotic disease after successful percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) is linked to future major adverse cardiovascular events (MACE).
- Intravascular ultrasound (IVUS) provides a more comprehensive assessment of coronary artery disease severity than angiography.
- Understanding the characteristics and impact of untreated lesions is crucial for improving patient outcomes.
Purpose of the Study:
- To characterize untreated atherosclerotic lesions after successful PCI in ACS patients.
- To evaluate the clinical impact of these residual lesions on long-term cardiovascular outcomes.
- To identify predictors of high-plaque burden lesions.
Main Methods:
- 697 ACS patients underwent 3-vessel grayscale and radiofrequency IVUS after successful PCI.
- Untreated lesions were prospectively characterized, and patients were followed for a median of 3.4 years.
- Major adverse cardiovascular events (MACE) were recorded and analyzed in relation to lesion characteristics.
Main Results:
- A significant burden of untreated lesions was identified by IVUS, with a mean plaque burden (PB) of 49.6%.
- 33% of patients had at least one lesion with PB ≥70% (PB70 lesion).
- Patients with PB70 lesions experienced higher 3-year MACE rates (20.8% vs. 7.7%) compared to those without, driven by untreated nonculprit lesions.
Conclusions:
- Untreated atherosclerotic burden is substantial even after successful PCI for ACS.
- PB70 lesions are common, particularly in proximal and mid-coronary segments, and are associated with more extensive atherosclerosis and vulnerable plaque features.
- The presence of PB70 lesions independently predicts an increased risk of future cardiovascular events.
Objectives:
The aim of this study was to characterize and evaluate the clinical impact of untreated atherosclerotic disease after percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS).
Background:
Residual atherosclerotic disease after successful PCI may predispose future major adverse cardiovascular events (MACE). Compared with intravascular ultrasound (IVUS), angiography underestimates the presence and severity of coronary artery disease.
Methods:
Following successful PCI of all clinically significant lesions in 697 patients with ACS, 3-vessel grayscale and radiofrequency IVUS was performed. Lesions were prospectively characterized, and patients were followed for a median of 3.4 years. A total of 3,229 untreated lesions (4.89 ± 1.98 lesions/patient) were identified by IVUS, with mean plaque burden (PB) of 49.6 ± 4.2%.
Results:
By angiography these nonculprit lesions were mild, with mean diameter stenosis of 38.9 ± 15.3%. At least 1 lesion with a PB ≥70% (PB70 lesion) was found in 220 (33%) patients. By multivariable analysis, a history of prior PCI and angiographic 3-vessel disease were independent predictors of PB70 lesions. Patients with PB70 lesions had greater total percent plaque volume, normalized PB, fibroatheromas, thin-cap fibroatheromas, and normalized volumes of necrotic core and dense calcium. Patients with PB70 lesions had greater 3-year rates of MACE due to untreated nonculprit lesions (20.8% vs. 7.7%, p < 0.0001). Among imaged nonculprit lesions, the proportion of PB70 lesions causing MACE was significantly greater than non-PB70 lesions (8.7% vs. 1.0%, p < 0.0001).
Conclusions:
After successful PCI of all angiographically significant lesions, overall untreated atherosclerotic burden remains high, and PB70 lesions are frequently present in the proximal and mid-coronary tree. Patients with PB70 lesions have greater atherosclerosis throughout the coronary tree, have more thin-cap fibroatheromas, and are at increased risk for future cardiovascular events. (
Prospect:
An Imaging Study in Patients With Unstable Atherosclerotic Lesions; NCT00180466).
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