Therapeutic Strategies - Preventive Therapy of Lipid-Rich Vulnerable Plaques – Jung-Min Ahn

Preventive Therapy for Lipid-Rich Vulnerable Plaque

Introduction to Preventive PCI

• Jung Minang from Asam Medical Center discusses the role of preventive therapy in managing lipid-rich vulnerable plaques, expressing a belief in the future significance of preventive PCI.

• Highlights established roles of PCI in reducing cardiac death and myocardial infarction (MI) based on randomized trials, particularly in patients with acute coronary syndrome (ACS).

Efficacy of Preventive PCI

• Discusses findings from various trials (e.g., KI trial, FAME II trial, ISCHEMIA trial), noting no significant differences in outcomes related to overall mortality or MI.

• Emphasizes that spontaneous MI reduction is a potential preventive effect of stenting, with studies showing a 30-40% reduction across different research.

Intravascular Imaging and High-Risk Plaques

• Mentions advancements over two decades in defining high-risk plaques using intravascular imaging techniques like grayscale IVUS and OCT.

• Points out that adverse plaque characteristics can increase cardiac events; recent data suggests vulnerable plaques are often found in significant stenosis rather than just mild cases.

Understanding FFR and Patient Outcomes

• Describes findings from a large FFR registry indicating that even patients with negative FFR can experience cardiac events, albeit at low rates over three years.

• Discusses the challenge of preventing future events originating from vulnerable plaques despite identifying high-risk characteristics through imaging.

The Preventive Trial Design

• Introduces the design of a new preventive trial comparing PCI against medical therapy for treating vulnerable plaques, initially planning to use bioresorbable scaffolds (BRS).

• Details criteria for patient inclusion based on imaging analysis and FFR results; emphasizes the importance of specific morphological and compositional criteria for defining non-flow limiting lesions.

Patient Characteristics and Study Findings

• Outlines primary endpoints focused on target vessel failure within two years post-randomization; describes patient demographics typical for PCI procedures.

• Notes screening process where 5,000 patients were evaluated leading to enrollment of 1,600 into two treatment arms; highlights key characteristics such as age and prevalence of diabetes among participants.

Preventive PCI: Insights and Outcomes

Key Findings on Preventive PCI Outcomes

• The study found that LDA cholesterol levels were significantly low at 64, indicating a potential benchmark for future preventive PCI trials. The primary composite outcome of target vessel failure at two years was notably lower in the OMT group (3.4%) compared to preventive PCI (0.4%).

• Significance of outcomes was maintained up to seven years, with a legion-level analysis showing that patient-oriented composite outcomes, including any cause mortality and myocardial infarction (MI), were significantly reduced by preventive PCI.

• Primary composite outcomes showed better results in the preventive PCI group, particularly regarding death from any cause and target factor MI at two years, highlighting the effectiveness of combining PCI with OMT.

• The numbers needed to treat indicated that 45 patients required preventive PCI to prevent one primary endpoint event and 87 patients to prevent one cardiac death or target vessel MI over two years.

• Conclusions suggest that preventive PCI resulted in a lower incidence of major adverse events compared to OMT alone in patients with non-flow limiting plaque, opening new avenues for research in this area.

Limitations and Future Directions

• Acknowledgment of limitations within the trial raises questions about optimal imaging techniques for assessing candidates for preventive PCI; further studies are necessary to determine best practices.

• Analysis revealed that plaque burden and lipid-rich plaques were significant predictors of cardiac events; however, lumen size did not correlate with future events, suggesting targeted approaches may be beneficial.

• The efficacy of preventive PCI varied based on the presence of lipid-rich plaques; it effectively reduced events when such plaques were present but showed no difference when absent.

• Discussion around treatment options highlighted DES as effective over time while considering DCB as a promising alternative due to its "leave nothing behind" philosophy despite mixed results from recent trials.

• Upcoming trials like the reverse trial aim to clarify which local treatments will be most effective moving forward; ongoing planning for new studies emphasizes comprehensive screening methods using advanced imaging techniques.