Author: Nicole Lou, Special Writer, MedPage Today March 12, 2021

According to a natural history study, shortly after intervention for MI, the remaining high-risk vulnerable plaques can be identified from catheter-based imaging.

The PROSPECT II team led by David reported that in the cohort of 898 MI survivors, 13.22% of the major cardiac events that occurred within 4 years were mostly due to untreated lesions, which were considered angiographic at the time of index MI. Benign and non-blood flow restriction Erlinge, MD, PhD, Lund University, Sweden, published in the March 13th issue of The Lancet.

Completely 8.0% of people cause cardiac death, MI, unstable angina, or progressive angina events due to non-criminal lesions identified by dedicated intracoronary near-infrared spectroscopy (NIRS) and intravascular ultrasound (IVUS) catheters.

"In contrast, in the original PROSPECT study and LRP study, the same proportion of events within 3 years were attributed to previously treated culprit lesions and untreated non-criminal lesions. Compared with previous studies, new findings during follow-up The lower event rate may be due to improved stent technology, more effective medications, and the use of IVUS to guide stent placement for the offender lesions treated in our study," the team noted.

In a related commentary, the two editorials raised the question of what practical experience can be learned from the three studies.

"How do health professionals translate this series of studies that add labor-intensive, measured intra-coronary artery-derived imaging variables to the busy practice of daily catheterization laboratories? Do we need [IVUS and NIRS]? Is a simple identification of block vulnerability sufficient?” Suppose Ron Waksman, MD, of MedStar Washington Hospital Center, Washington, DC, and Rebecca Torguson, MD, of Icahn School of Medicine, Mount Sinai, New York City.

Once a vulnerable plaque is detected, the next question is how to deal with it.

Waksman and Torguson noted that PCKS9 inhibitors are being tested in this case in the FITTER and YELLOW III trials, and local stent implantation is being compared with the best drug treatment in PREVENT.

"The answer is likely to be a patient-centered approach that combines a combination of treatments that target the patient's specific anatomy, the number of non-culprit lesions with plaque vulnerability, and plaque composition," the two said.

PROSPECT II was performed in 16 hospitals in Denmark, Norway and Sweden from 2014 to 2017. Its main findings were reported for the first time at the TCT Connect meeting in 2020, showing the impact of Absorb bioabsorbable vascular stents on vulnerable plaques.

Participants included 898 patients (17% were women, with a median age of 63 years) who survived MI within 4 weeks before enrollment. After treating all coronary artery lesions that restricted blood flow, it was found that the median number of non-criminal lesions for each person was 4.0.

In the baseline angiographic diameter stenosis, untreated lesions averaged 46.9% and increased to an average of 68.4% at the time of the event.

Independent predictors of major adverse cardiovascular events (MACE) related to non-criminal lesions are hyperlipid lesions (MaxLCBI4mm ≥324.7 on NIRS) and large plaque burden (70% or higher on IVUS). The minimum lumen area is 4.0 mm2 or less, which loses statistical significance as an adjusted predictor.

Even so, Erlinge's group said that in future research, all three factors can be used to define the characteristics of vulnerable plaques. "Therefore, the combination of NIRS and IVUS is complementary because they overcome each other's limitations."

By 4 years, the incidence of MACE per lesion for hyperlipid lesions with large plaque burden is 7%, and the risk of MACE for patients with at least one of these plaques is 13%.

Erlinge’s research team said: “User-friendly methods of identifying these so-called vulnerable plaques before they progress can enable pharmacological or other strategies to stabilize plaques, prevent atherosclerosis progression, and improve outcomes.”

An embedded analysis in the study suggests that percutaneous coronary intervention for non-obstructive vulnerable plaques may be safe and effective.

"However, the conventional treatment of non-ischemic vulnerable plaques (whether it is intensive drug therapy or local intervention) determined by non-invasive or invasive imaging cannot be recognized until large-scale, sufficiently effective randomized trials are conducted. "The author emphasized.

In addition, PROSPECT II's selection of MI survivors with recent non-criminal lesions (defined as having at least 40% plaque burden) may exclude non-criminal lesions with high lipid content and low plaque burden, which will result in the loss of key Of vulnerable plaques, Waxman and Togsen warned.

Nicole Lou is a reporter for MedPage Today. She reports on cardiology news and other medical developments. follow

PROSPECT II was carried out with funding from Abbott Vascular, Infraredx and The Medicines Company.

Erlinge reported on speaker fees from Amgen, AstraZeneca, Bayer, and Chiesi, as well as advisory board fees from Bayer, Boehringer Ingelheim, and Sanofi.

Waksman announced that it holds equity in Transmural Systems and Pi-Cardia; holds equity in MedAlliance and collects consulting fees; receives consulting and advisory board fees from Abbott Vascular; receives advisory board and consulting fees from Medtronic and Philips Volcano; speaker fees and Grants from AstraZeneca and Casey; consulting fees and grants from Biotronik; and grants from Boston Scientific, advisory board fees and consulting fees.

Source reference: Erlinge D et al. "Identifying vulnerable plaques and patients through near-infrared spectroscopy and ultrasound (PROSPECT II) in coronary arteries: a prospective natural history study" "The Lancet 2021"; DOI: 10.1016/S0140- 6736(21)00249-X.

Source reference: Waksman R, Torguson R "Vulnerable Plaques Detected: Consider the Time of Treatment" Lancet 2021; DOI: 10.1016/S0140-6736(21)00504-3.

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