PCI may benefit patients with unblocked arteries but vulnerable plaque vs. medical therapy (2024)

Key takeaways:

• For patients with vulnerable plaque but no flow-limiting stenosis, PCI provided better clinical outcomes than medical therapy at 2 years.
• The results held at 7 years and may suggest a new population for PCI.

ATLANTA — Preventive PCI plus optimal medical therapy was superior to optimal medical therapy alone for patients with nonflow-limiting vulnerable coronary plaques, according to the results of the PREVENT trial.

The patient population of 1,606 included those with coronary stenosis greater than 50% but negative fractional flow reserve ( 0.8) who had vulnerable plaque as determined by meeting at least two of the following criteria on intracoronary imaging: minimal lumen area of 4 mm² or less, plaque burden greater than 70%, thin-capped fibroatheroma by OCT or radiofrequency IVUS or lipid-rich plaque by near-infrared spectroscopy (maximum lipid core burden index in a 4 mm segment > 315), Seung-Jung Park, MD, professor of medicine at University of Ulsan College of Medicine Asan Medical Center, Seoul, South Korea, said during a presentation at the American College of Cardiology Scientific Session.

PCI for nonflow-limiting vulnerable plaques

“Intracoronary imaging-defined vulnerable plaque has more of a tendency to increase major adverse cardiac events,” Park said during the presentation. “Optimal medical therapy is the standard approach to stabilize plaque vulnerability. However, the safety and effectiveness of focal preventive PCI for nonflow-limiting vulnerable plaques are unknown. So, [PREVENT was conducted] in order to assess whether focal preventive PCI of nonflow-limiting, imaging-defined vulnerable plaques improves clinical outcomes compared with optimal medical therapy alone.”

Patients were randomly assigned to PCI plus optimal medical therapy (mean age, 64 years; 76% men) or optimal medical therapy alone (mean age, 65 years; 71% men). The primary outcome was target vessel failure, defined as cardiac death, target vessel MI, ischemia-driven target vessel revascularization or hospitalization for unstable or progressive angina, at 2 years. The results were simultaneously published in The Lancet.

The primary outcome occurred in 0.4% of the PCI group and 3.4% of the medical therapy group at 2 years (HR = 0.11; 95% CI, 0.03-0.36; log-rank P = .0003), and the results were sustained out to 7 years (6.5% vs. 9.4%; HR = 0.54; 95% CI, 0.33-0.87; log-rank P = .0097), Park said during the presentation.

The patient-oriented composite outcome of all-cause death, any MI or any repeat revascularization also favored the PCI group at 2 years (3% vs. 5.2%) and at 7 years (14.4% vs. 19.3%; HR = 0.69; 95% CI, 0.5-0.95; log-rank P = .022), he said.

“Our key findings might provide novel insights on the role of preventive PCI on nonflow-limiting high-risk vulnerable plaques in the future,” Park said during the presentation.

‘Brave to challenge the paradigm’

In a discussion after the presentation, J. Dawn Abbott, MD, FACC, FSCAI, associate chief of faculty development and academic advancement in the division of cardiology and professor of medicine at The Warren Alpert Medical School of Brown University and director of interventional cardiology and cardiac catheterization laboratories at Lifespan Cardiovascular Institute at Rhode Island Hospital and The Miriam Hospital, said: “It is brave to challenge the paradigm that medical therapy alone is sufficient to treat vulnerable moderate nonobstructive plaque. [There were] remarkably high rates of safety and great long-term outcomes with an interventional approach.”

Reference:

• Park SJ, et al. Lancet. 2024;doi:10.1016/S0140-6736(24)00413-6.