CT-Guided Lipid-Lowering Therapy Leading to Functional Resolution of Ischemia

Aggressive lipid-lowering therapy may lead to regression of atherosclerosis; there are scarce data supporting such an approach for improving coronary physiological indexes. Serum low-density lipoprotein cholesterol is the primary target for lipid-lowering therapy. Computed tomography (CT)-derived assessments of plaque composition and coronary physiology are promising targets for individualized lipid-lowering strategies.

A 62-year-old woman presented with intermittent angina on moderate exertion. Coronary CT angiography revealed a significant focal stenosis in the left circumflex artery (fractional flow reserve based on CT [FFR_CT]: 0.74, pressure pullback gradient: 0.75) and non-flow-limiting diffuse disease in the left anterior descending artery (FFR_CT: 0.83, pressure pullback gradient: 0.59). CT-guided intensive lipid-lowering therapy was initiated. Follow-up showed a reduction in total plaque volume (-97 mm³ [Δ19%]), improvement in FFR_CT in the left circumflex artery (0.93) and left anterior descending artery (0.88), and resolution of symptoms.

This case demonstrates that CT-guided lipid-lowering therapy can reverse plaque burden and ischemia in a patient with a flow-limiting epicardial lesion. The therapeutic targets proposed here, addressing both morphological plaque characteristics and coronary physiology parameters, go beyond the traditional goal of lowering low-density lipoprotein cholesterol levels. Pharmacological strategy guided by precise plaque imaging and functional assessment requires confirmation in larger clinical studies.

CT-guided pharmacotherapy aimed at improving both plaque composition and epicardial coronary flow parameters may represent an alternative to uniform treatment strategies based on cholesterol levels.