ACC.24: New data suggest early PCI limits risks of vulnerable plaques—cardiologists are skeptical
Treating high-risk plaques with preventive percutaneous coronary intervention (PCI) before the patient suffers a heart attack may limit the long-term risk of adverse outcomes, according to late-breaking data presented at ACC.24, the annual meeting of the American College of Cardiology (ACC). The study was simultaneously published in The Lancet.[1]
The PREVENT study included data from more than 1,600 adult patients treated in South Korea, Japan, Taiwan or New Zealand. The mean patient age was 64 years old, and 73% were men. Plaques were considered vulnerable if at least two of these findings were present: a minimal lumina area of ≤4.0 mm2, plaque burden greater than 70%, thin-cap fibroatheroma identified by optical coherence tomography or intravascular ultrasound (IVUS) or lipid-rich plaque as identified by near-infrared spectroscopy. None of the plaques were limiting blood flow through the artery enough to be traditionally recommended for interventional treatment.
Patients were randomized to either undergo early PCI and optical medical therapy (OMT) or OMT alone. Overall, the study’s primary endpoint—a composite of cardiovascular death, target-vessel myocardial infarction, ischemia-driven target-vessel revascularization or hospitalization for unstable/progressive angina—was seen in 0.4% of early PCI patients and 3.4% of OMT patients after a follow-up period of two years. In fact, early PCI was associated with improvements in each individual outcome included in that primary endpoint.
When researchers extended the follow-up period to more than four years, early PCI was still associated with significant improvements in terms of limiting these adverse cardiovascular outcomes.
“PREVENT has now shown that preventive PCI may reduce the two-year and long-term risks of major cardiac events arising from vessels containing vulnerable plaques,” said lead author Seung-Jung Park, MD, professor in the division of cardiology at Asan Medical Center at the University of Ulsan College of Medicine in Seoul, South Korea. “These findings demonstrate that the focal treatment of high-risk vulnerable plaques may improve patient prognosis beyond optimal medical therapy alone.”
Park et al. did note that additional research is still needed to determine if these findings can be generalizable to a larger patient population.
The team’s analysis was funded by the Cardiovascular Research Foundation and multiple leading healthcare vendors, including Abbott and Philips.
Cardiologists share initial concerns with PREVENT data
Should care teams let these findings change how they practice on a day-to-day basis? Not so fast, according to a panel of ACC experts who reviewed the late-breaking findings.
Valentin Fuster, MD, PhD, president of Mount Sinai Fuster Heart Hospital and editor-in-chief of the Journal of American College of Cardiology, led the group, voicing his initial concerns before asking several colleagues to share their own thoughts.
Rasha Al-Lamee, MD, PhD, an interventional cardiologist with Imperial College Healthcare NHS Trust and Imperial College London, warned that cardiologists should remain cautious when reviewing these findings.
“The criteria for vulnerable plaque in this population was, for the vast majority, a lesion that was tight on IVUS or a significant plaque burden,” she said. “It was actually a very small proportion of patients that had thin cap atheroma, that had the various vulnerable plaque characteristics we look for. And importantly, over 70% of patients had gray-scale IVUS, which is not very good for looking at these vulnerable features.”
Meanwhile, Clyde W. Yancy, MD, MSc, chief of cardiology with the Northwestern Medicine Feinberg School of Medicine, described the findings as “frightening” because of how easily they could be overstated.
“If this is overinterpreted, I don’t know how we control that,” he said. “I like the idea of focusing on the plaque—deciding which plaques are stable, which are vulnerable—but if you extend this interpretation as they printed it, that frightens me.”
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.