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Fractional Flow Reserve-Negative High-Risk Plaques and Clinical Outcomes After Myocardial Infarction
Jan-Quinten Mol1, Rick H J A Volleberg1, Anouar Belkacemi2
1Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands.
Insights
High-risk plaques in nonculprit lesions after myocardial infarction (MI) are linked to worse outcomes. Optical coherence tomography (OCT) identified these plaques, suggesting a need for new treatments beyond FFR-guided revascularization.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Imaging
Background:
- Patients with myocardial infarction (MI) experience high rates of recurrent major adverse cardiovascular events (MACE) even after fractional flow reserve (FFR)-guided complete revascularization.
- FFR-negative nonculprit lesions may harbor high-risk plaques contributing to these recurrences.
Purpose of the Study:
- To evaluate the association between optical coherence tomography (OCT)-identified high-risk plaques in FFR-negative nonculprit lesions and the occurrence of MACE in MI patients.
Main Methods:
- PECTUS-obs study enrolled patients with MI undergoing OCT on FFR-negative nonculprit lesions (FFR > 0.80).
- High-risk plaque defined by ≥2 criteria: lipid arc ≥90°, fibrous cap <65 μm, or plaque rupture/thrombus.
- Compared MACE rates (all-cause mortality, nonfatal MI, unplanned revascularization) at 2-year follow-up.
Main Results:
- 143 of 420 patients (34.0%) had at least one high-risk plaque.
- MACE occurred in 15.4% of patients with high-risk plaques vs. 8.3% without (HR, 1.93; P=.02).
- Unplanned revascularizations were higher in the high-risk plaque group (9.8% vs. 4.3%; P=.02).
Conclusions:
- High-risk plaques in FFR-negative nonculprit lesions are associated with worse clinical outcomes in MI patients.
- The increased MACE risk is primarily driven by unplanned revascularizations.
- Findings suggest a need for novel therapeutic strategies targeting high-risk plaques beyond current revascularization guidelines.
Importance:
Even after fractional flow reserve (FFR)-guided complete revascularization, patients with myocardial infarction (MI) have high rates of recurrent major adverse cardiovascular events (MACE). These recurrences may be caused by FFR-negative high-risk nonculprit lesions.
Objective:
To assess the association between optical coherence tomography (OCT)-identified high-risk plaques of FFR-negative nonculprit lesions and occurrence of MACE in patients with MI.
Design, Setting, And Participants:
PECTUS-obs (Identification of Risk Factors for Acute Coronary Events by OCT After STEMI [ST-segment elevation MI] and NSTEMI [non-STEMI] in Patients With Residual Non-flow Limiting Lesions) is an international, multicenter, prospective, observational cohort study. In patients presenting with MI, OCT was performed on all FFR-negative (FFR > 0.80) nonculprit lesions. A high-risk plaque was defined containing at least 2 of the following prespecified criteria: (1) a lipid arc at least 90°, (2) a fibrous cap thickness less than 65 μm, and (3) either plaque rupture or thrombus presence. Patients were enrolled from December 14, 2018, to September 15, 2020. Data were analyzed from December 2, 2022, to June 28, 2023.
Main Outcome And Measure:
The primary end point of MACE, a composite of all-cause mortality, nonfatal MI, or unplanned revascularization, at 2-year follow-up was compared in patients with and without a high-risk plaque.
Results:
A total of 438 patients were enrolled, and OCT findings were analyzable in 420. Among included patients, mean (SD) age was 63 (10) years, 340 (81.0) were men, and STEMI and non-STEMI were equally represented (217 [51.7%] and 203 [48.3%]). A mean (SD) of 1.17 (0.42) nonculprit lesions per patient was imaged. Analysis of OCT images revealed at least 1 high-risk plaque in 143 patients (34.0%). The primary end point occurred in 22 patients (15.4%) with a high-risk plaque and 23 of 277 patients (8.3%) without a high-risk plaque (hazard ratio, 1.93 [95% CI, 1.08-3.47]; P = .02), primarily driven by more unplanned revascularizations in patients with a high-risk plaque (14 of 143 [9.8%] vs 12 of 277 [4.3%]; P = .02).
Conclusions And Relevance:
Among patients with MI and FFR-negative nonculprit lesions, the presence of a high-risk plaque is associated with a worse clinical outcome, which is mainly driven by a higher number of unplanned revascularizations. In a population with a high recurrent event rate despite physiology-guided complete revascularization, these results call for research on additional pharmacological or focal treatment strategies in patients harboring high-risk plaques.
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