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Published on: November 10, 2017
Concomitant Coronary Atheroma Regression and Stabilization in Response to Lipid-Lowering Therapy
Flavio G Biccirè1, Jonas Häner2, Sylvain Losdat3
1Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland. Electronic address: https://twitter.com/FBiccire.
Insights
Triple regression, a marker of plaque stabilization, occurred in one-third of acute myocardial infarction patients on high-intensity lipid-lowering therapy. This plaque regression was linked to alirocumab treatment and reduced cardiovascular events.
Area of Science:
- Cardiology
- Vascular Biology
- Pharmacology
Background:
- The characteristics and outcomes of "triple regression" (atheroma volume reduction, lipid content reduction, fibrous cap thickening) in patients on high-intensity lipid-lowering therapy are not well understood.
- Acute myocardial infarction (AMI) patients represent a critical population where plaque stabilization is highly desirable.
Purpose of the Study:
- To investigate the rates, predictors, and prognostic significance of "triple regression" in AMI patients receiving high-intensity lipid-lowering therapy.
- To evaluate the impact of alirocumab, a PCSK9 inhibitor, on achieving triple regression.
Main Methods:
- The PACMAN-AMI trial enrolled AMI patients on high-intensity statin therapy, comparing alirocumab to placebo.
- Serial intravascular ultrasound, near-infrared spectroscopy, and optical coherence tomography were used to assess plaque characteristics.
- Triple regression was defined by simultaneous atheroma volume reduction, lipid core burden index reduction, and fibrous cap thickness increase.
Main Results:
- Triple regression was observed in 31.7% of patients, with higher rates in the alirocumab group (40.8%) versus placebo (23.0%).
- Achieving triple regression was independently predicted by alirocumab treatment and higher baseline lipid core burden.
- Patients achieving triple regression had significantly lower on-treatment LDL cholesterol and experienced fewer major adverse cardiovascular events.
Conclusions:
- Triple regression occurs in about one-third of AMI patients on intensive lipid-lowering therapy and is associated with improved cardiovascular outcomes.
- Alirocumab treatment significantly increases the likelihood of achieving triple regression, highlighting its role in plaque stabilization.
- These findings underscore the prognostic value of plaque regression and the efficacy of PCSK9 inhibition in managing coronary atherosclerosis.
Background:
The frequency, characteristics, and outcomes of patients treated with high-intensity lipid-lowering therapy and showing concomitant atheroma volume reduction, lipid content reduction, and increase in fibrous cap thickness (ie, triple regression) are unknown.
Objectives:
This study was designed to investigate rates, determinants, and prognostic implications of triple regression in patients presenting with acute myocardial infarction and treated with high-intensity lipid-lowering therapy.
Methods:
The PACMAN-AMI (Effects of the PCSK9 Antibody Alirocumab on Coronary Atherosclerosis in Patients with Acute Myocardial Infarction) trial used serial intravascular ultrasound, near-infrared spectroscopy, and optical coherence tomography to compare the effects of alirocumab vs placebo in patients receiving high-intensity statin therapy. Triple regression was defined by the combined presence of percentage of atheroma volume reduction, maximum lipid core burden index within 4 mm reduction, and minimal fibrous cap thickness increase. Clinical outcomes at 1-year follow-up were assessed.
Results:
Overall, 84 patients (31.7%) showed triple regression (40.8% in the alirocumab group vs 23.0% in the placebo group; P = 0.002). On-treatment low-density lipoprotein cholesterol levels were lower in patients with vs without triple regression (between-group difference: -27.1 mg/dL; 95% CI: -37.7 to -16.6 mg/dL; P < 0.001). Triple regression was independently predicted by alirocumab treatment (OR: 2.83; 95% CI: 1.57-5.16; P = 0.001) and a higher baseline maximum lipid core burden index within 4 mm (OR: 1.03; 95% CI: 1.01-1.06; P = 0.013). The composite clinical endpoint of death, myocardial infarction, and ischemia-driven revascularization occurred less frequently in patients with vs without triple regression (8.3% vs 18.2%; P = 0.04).
Conclusions:
Triple regression occurred in one-third of patients with acute myocardial infarction who were receiving high-intensity lipid-lowering therapy and was associated with alirocumab treatment, higher baseline lipid content, and reduced cardiovascular events. (Vascular Effects of Alirocumab in Acute MI-Patients [PACMAN-AMI]; NCT03067844).
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