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Nonculprit Lesion Plaque Morphology in Patients With ST-Segment-Elevation Myocardial Infarction: Results From the
Natalia Pinilla-Echeverri1, Shamir R Mehta1, Jia Wang1
1Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (N.P.-E., S.R.M., J.W., H.N., B.M., T.S.).
Insights
Complete revascularization improves outcomes in ST-segment-elevation myocardial infarction. Vulnerable plaque, specifically thin-cap fibroatheroma (TCFA), is common in nonculprit lesions, potentially explaining this benefit.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Imaging
Background:
- Complete revascularization improves outcomes in ST-segment-elevation myocardial infarction (STEMI).
- The role of nonculprit lesion vulnerability in this benefit remains unclear.
- Understanding plaque characteristics in nonculprit lesions is crucial for optimizing treatment strategies.
Purpose of the Study:
- To investigate the prevalence and characteristics of vulnerable plaque in nonculprit lesions after primary percutaneous coronary intervention (PCI) in STEMI patients with multivessel disease.
- To determine if vulnerable plaque morphology in nonculprit lesions correlates with obstructive potential.
Main Methods:
- Prospective substudy of the COMPLETE trial involving 93 STEMI patients with multivessel disease.
- Optical coherence tomography (OCT) imaging of nonculprit coronary arteries and culprit vessels.
- Classification of lesions as obstructive or nonobstructive and as thin-cap fibroatheroma (TCFA) or non-TCFA based on OCT criteria.
Main Results:
- Nearly 50% of patients had at least one obstructive nonculprit lesion with TCFA.
- Obstructive nonculprit lesions showed a higher prevalence of TCFA (35.4%) compared to nonobstructive lesions (23.2%).
- Obstructive TCFAs exhibited significantly more lipid content and macrophages compared to non-TCFAs.
Conclusions:
- Vulnerable plaque, particularly TCFA, is prevalent in obstructive nonculprit lesions in STEMI patients.
- The high occurrence of complex plaque morphology in these lesions may underlie the benefits of complete revascularization.
- OCT imaging provides valuable insights into plaque vulnerability in the context of multivessel coronary artery disease.
Background:
Complete revascularization with routine percutaneous coronary intervention of nonculprit lesions after primary percutaneous coronary intervention improves outcomes in ST-segment-elevation myocardial infarction. Whether this benefit is associated with nonculprit lesion vulnerability is unknown.
Methods:
In a prospective substudy of the COMPLETEs trial (Complete vs Culprit-Only Revascularization to Treat Multi-Vessel Disease After Early PCI for STEMI), we performed optical coherence tomography of at least 2 coronary arteries before nonculprit lesion percutaneous coronary intervention in 93 patients with ST-segment-elevation myocardial infarction and multivessel disease; and the ST-segment-elevation myocardial infarction culprit vessel if there was unstented segment amenable to imaging. Nonculprit lesions were categorized as obstructive (≥70% stenosis by visual angiographic assessment) or nonobstructive, and as thin-cap fibroatheroma (TCFA) or non-TCFA by optical coherence tomography criteria. TCFA was defined as a lesion with mean fibrous cap thickness <65 μm overlying a lipid arc >90°.
Results:
On a patient level, at least one obstructive TCFA was observed in 44/93 (47%) of patients. On a lesion level, there were 58 TCFAs among 150 obstructive nonculprit lesions compared with 74 TCFAs among 275 nonculprit lesions (adjusted TCFA prevalence: 35.4% versus 23.2%, P=0.022). Compared with obstructive non-TCFAs, obstructive TCFAs had similar lesion length (23.1 versus 20.8 mm, P=0.16) but higher lipid quadrants (55.2 versus 19.2, P<0.001), greater mean lipid arc (203.8° versus 84.5°, P<0.001), and more macrophages (97.1% versus 54.4%, P<0.001) and cholesterol crystals (85.8% versus 44.3%, P<0.001). For nonobstructive lesions, TCFA lesions had similar lesion length (16.7 versus 14.6 mm, P=0.11), but more lipid quadrants (36.4 versus 13.5, P<0.001), and greater mean lipid arc (191.8° versus 84.2°, P<0.001) compared with non-TCFA.
Conclusions:
Among patients who underwent optical coherence tomography imaging in the COMPLETE trial, nearly 50% had at least one obstructive nonculprit lesion containing complex vulnerable plaque. Obstructive lesions more commonly harbored vulnerable plaque morphology than nonobstructive lesions. This may help explain the benefit of routine percutaneous coronary intervention of obstructive nonculprit lesions in patients with ST-segment-elevation myocardial infarction and multivessel disease. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01740479s.
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