Plaque Morphology-Dependent Regression of Tandem Coronary Plaques Under Intensive Lipid-Lowering Therapy

We report a 54-year-old woman with stable angina who exhibited heterogeneous responses of tandem left anterior descending artery (LAD) plaques to intensive lipid-lowering therapy. Coronary CT angiography performed at another hospital suggested diffuse disease, and she presented to our clinic for a second opinion. Intravascular ultrasound revealed a lipid-rich proximal LAD lesion and a fibrous-predominant distal lesion, along with a smaller intermediate lesion. Fractional flow reserve (FFR) pullback showed distal LAD FFR of 0.50, increasing to 0.73 across the distal lesion (ΔFFR + 0.23) and to 0.95 across the proximal lesion (ΔFFR + 0.22). Although PCI was considered, in accordance with the patient's preference and guideline recommendations, medical therapy with high-intensity statin, ezetimibe, aspirin, nebivolol, and isosorbide dinitrate was initiated. LDL-C decreased to < 35 mg/dL and remained consistently suppressed. After 2 years, serial CT and intravascular ultrasound (IVUS) demonstrated near-complete regression of the lipid-rich proximal lesion with lumen enlargement, a marked reduction in IVUS features consistent with a lipid-rich core, and attenuation of its lesion-specific physiological contribution (ΔFFR + 0.02), whereas the distal fibrous lesion remained stable (ΔFFR + 0.20) (lesion-specific functional improvement defined as attenuation of lesion-specific ΔFFR contribution on FFR pullback). The intermediate lesion also regressed morphologically, although it was not assessed functionally. The patient remained asymptomatic with preserved exercise capacity. This case suggests that plaque morphology may influence the response to lipid-lowering therapy and highlights the value of multimodality imaging with lesion-specific physiological assessment in individualized management of stable coronary disease.