Management of Coronary Vulnerable Plaques: A Focus on Preventive Percutaneous Coronary Intervention

Vulnerable or high-risk coronary plaques are usually referred to as angiographically mild to moderate lesions characterized by a large plaque burden, positive vessel remodeling, thin fibrous cap, and large necrotic/lipid core. According to several pathology studies, these plaques represent the substrate of coronary thrombosis in about two-thirds of cases; therefore, there has been increasing interest in detecting and treating vulnerable plaques (VPs). Nowadays, VP detection is possible through noninvasive and invasive imaging techniques, such as coronary computed tomography, magnetic resonance imaging, intravascular ultrasound, optical coherence tomography, and near-infrared spectroscopy. Since VPs were shown to be associated with cardiovascular events in observational studies, pharmacological and non-pharmacological strategies have been investigated to achieve a regression and/or a passivation of these plaques. In addition to pharmacological therapies, mainly focused on lipid-lowering agents, there has been a recent growing interest in interventional therapies, including coronary scaffolds, stents, and drug-coated balloons. This led to the concept of preventive percutaneous coronary intervention, which, unlike the treatment of culprit lesions in acute coronary syndromes or of ischemia-inducing stenoses, as recommended by guidelines, implies the treatment of angiographically and functionally non-significant lesions based on one or more high-risk plaque characteristics as identified by noninvasive or intracoronary imaging. This article provides an updated review of key concepts in defining and detecting VPs; their prognostic value and available pharmacological and interventional management evidence will also be discussed.