Nonculprit Vulnerable Plaques and Prognosis in Myocardial Infarction With Versus Without ST-Segment Elevation: A
Pernille G Thrane1,2, Michael Maeng1,2, Akiko Maehara3,4
1Department of Cardiology, Aarhus University Hospital, Denmark (P.G.T., M. Maeng, H.E.B.).
Insights
High-risk plaques were similarly prevalent in ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) patients. Outcomes from untreated nonculprit lesions were also comparable, suggesting similar revascularization strategies for both patient groups.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Biology
Background:
- Clinical guidelines differ on revascularization for nonculprit lesions in ST-elevation myocardial infarction (STEMI) versus non-STEMI (NSTEMI).
- The prevalence of high-risk vulnerable plaques and their impact on outcomes in STEMI versus NSTEMI is not well understood.
Purpose of the Study:
- To compare the prevalence of untreated high-risk vulnerable plaques in nonculprit lesions between STEMI and NSTEMI patients.
- To evaluate the long-term outcomes associated with these nonculprit lesions in both patient groups.
Main Methods:
- The PROSPECT II study enrolled 898 patients with recent myocardial infarction undergoing 3-vessel angiography.
- Near-infrared spectroscopy and intravascular ultrasound identified two-feature high-risk plaques (plaque burden ≥70% and lipid core burden index ≥324.7).
- Major adverse cardiovascular events (MACE) from untreated nonculprit lesions were tracked for a median of 3.7 years.
Main Results:
- The prevalence of two-feature high-risk plaques at the lesion level was slightly higher in STEMI (12.8%) vs. NSTEMI (10.1%), but similar at the patient level (38.8% vs. 32.7%).
- Prevalence of plaques meeting at least one high-risk criterion was also similar between STEMI and NSTEMI groups.
- Four-year rates of nonculprit lesion-related MACE (8.6% vs. 7.8%) and all MACE (14.2% vs. 13.0%) were comparable between STEMI and NSTEMI patients.
Conclusions:
- The per-patient prevalence of high-risk vulnerable plaques is comparable in STEMI and NSTEMI.
- Long-term incidence of major adverse cardiovascular events arising from nonculprit lesions is similar in both STEMI and NSTEMI.
- These findings support a similar revascularization strategy for nonculprit lesions in STEMI and NSTEMI patients post-culprit lesion management.
Background:
Clinical guidelines recommend different revascularization strategies for nonculprit lesions in patients with ST-segment-elevation myocardial infarction (STEMI) versus non-STEMI (NSTEMI). Whether the prevalence of untreated high-risk vulnerable plaques differs in STEMI and NSTEMI and affects their outcomes is unknown.
Methods:
In PROSPECT II (Providing Regional Observations to Study Predictors of Events in the Coronary Tree II), a multicenter, prospective natural history study, patients with recent myocardial infarction underwent 3-vessel coronary angiography with coregistered near-infrared spectroscopy and intravascular ultrasound after successful percutaneous coronary intervention of obstructive lesions from 2014 through 2017. Two-feature high-risk plaques were defined as those with both plaque burden ≥70% and maximum lipid core burden index over any 4-mm segment ≥324.7. The primary end point was major adverse cardiovascular events arising from untreated nonculprit lesions during a median 3.7-year follow-up.
Results:
Of 898 patients, 199 (22.2%) with 849 nonculprit lesions had STEMI and 699 (77.8%) with 2784 nonculprit lesions had NSTEMI. By intravascular ultrasound, the median nonculprit lesion length was 17.4 mm (interquartile range, 16.3-18.5) in STEMI and 17.7 mm (interquartile range, 17.1-18.4) in NSTEMI (P=0.63), and the median minimal lumen area was 5.5 mm2 (interquartile range, 5.3-5.7 mm2) in STEMI and 5.5 mm2 (interquartile range, 5.3-5.6 mm2) in NSTEMI (P=0.99). At the lesion level, the prevalence of 2-feature high-risk nonobstructive nonculprit plaques was slightly higher in patients with STEMI than in patients with NSTEMI (12.8% versus 10.1%; P=0.03). At the patient level, however, the prevalence of 2-feature high-risk plaques was similar in STEMI versus NSTEMI (38.8% versus 32.7%; P=0.11). The prevalence of patients with 1 or more lesions meeting at least 1 high-risk plaque criterion was also similar (plaque burden ≥70%, 63.3% versus 57.8% [P=0.16]; maximum lipid core burden index over any 4-mm segment ≥324.7, 63.3% versus 57.6% [P=0.15]). The 4-year rates of nonculprit lesion-related major adverse cardiovascular events were similar in STEMI versus NSTEMI (8.6% versus 7.8%; hazard ratio, 1.02 [95% CI, 0.57-1.81]; P=0.95), as were the rates of all major adverse cardiovascular events (14.2% versus 13.0%; hazard ratio, 1.06 [95% CI, 0.68-1.64]; P=0.80).
Conclusions:
In the PROSPECT II study, the per-patient prevalence of high-risk vulnerable plaques was comparable in STEMI versus NSTEMI, as was the overall long-term incidence of nonculprit lesion-related and all major adverse cardiovascular events. These results support a similar revascularization strategy for nonculprit lesions in patients with STEMI or NSTEMI after culprit lesion management.
Registration:
URL: https://www.clinicaltrials.gov; Unique identifier: NCT02171065.
More Related Videos
Related Concept Videos
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:30Acute Coronary Syndrome I: Introduction
01:27Angina II: Classification
01:25Imaging Studies for Cardiovascular System VI: Calcium -Scoring CT
01:21Aneurysm II: Clinical Manifestations and Diagnostic Studies