PERCUTANEOUS CORONARY INTERVENTION VERSUS DRUG THERAPY IN THE TREATMENT OF UNSTABLE CORONARY ARTERY PLAQUES

Highlights

• A prospective randomized trial comparing the effectiveness of two approaches for the treatment of unstable plaque in patients with coronary artery disease was performed
• The most effective method in detecting unstable plaques is optical coherence tomography, which has demonstrated that 66% of patients have high-risk criteria, which underscores the importance of accurate diagnosis and an individual approach to treatment.

Background. The most common cause of acute coronary syndrome is the rupture and thrombosis of an unstable plaque. A plaque with vulnerable plaque characteristics increases the risk of major cardiac events, despite the absence of ischemia. The high resolution of optical coherence tomography allows for the assessment of not only the plaque volume and character but also the thin plaque capsule, an advantage over other imaging methods. Plaque stabilization using PCI remains a widely discussed treatment option and may be beneficial.

Aim. To compare the annual treatment outcomes of patients with mild coronary plaques treated with prophylactic PCI with OMT or OMT.

Methods. All patients with stable coronary artery disease and single-vessel borderline stenosis ranging from 50% to 89% in diameter underwent OCT to identify unstable plaque criteria. If two or more unstable plaque criteria were present, patients were randomized into two groups. One group underwent prophylactic PCI with OMT, while the other group received OMT alone. After 12 months, the two groups were compared for the following endpoints: angina recurrence, myocardial infarction, all-cause death, and target lesion revascularization. A composite endpoint, including all of the above outcomes, was also assessed.

Results. The study included 96 patients with coronary artery disease and angiographically borderline coronary artery disease. Patients with vulnerable plaque criteria according to OCT (n = 64) were randomized to the PCI with OMT or OMT groups with a subsequent follow-up of 12 months. During the 1-year follow-up period, no cases of repeat target lesion revascularization or myocardial infarction were detected. There was one cardiovascular death in the PCI group, while there were no deaths in the OMT group (3.1% and 0%, p = 0.574, respectively). However, the PCI group had a significant advantage in terms of residual angina compared to OMT at the 1-year follow-up stage (12.5% ​​and 43.8%, p = 0.027, respectively).

Conclusions. Prophylactic PCI with OMT has demonstrated benefit in terms of residual angina compared with OMT in the treatment of patients with chronic CAD and the presence of unstable plaque.

1. Haibo Jia, Jiannan Dai, Luping He, Yishuo Xu et al., EROSION III: A Multicenter RCT of OCT-Guided Reperfusion in STEMI With Early Infarct Artery Patency. JACC Cardiovascular Interventions 2022 25;15(8):846-856. https://doi.org/10.1016/j.jcin.2022.01.298.

2. Kochergin N.A., Ganyukov V.I. Randomized trial of preventive revascularization of unstable coronary artery plaques in patients with chronic ischemic heart disease. Complex problems of cardiovascular diseases. 2019; 8 (4S): 104-110. (In Russ.). https://doi.org/10.17802/2306-1278-2019-8-4S-104-110.

3. Thomas W Johnson, Lorenz Räber, Carlo di Mario, Christos Bourantas et al. Clinical use of intracoronary imaging. Part 2: acute coronary syndromes, ambiguous coronary angiography findings, and guiding interventional decision-making: an expert consensus document of the European Association of Percutaneous Cardiovascular Interventions. European Heart Journal 2019 14; 40 (31): 2566-2584. https://doi.org/10.1093/eurheartj/ehz332.

4. Arnt A. A., Kolesnikov A. Yu., Kochergin N.A. Artificial neural network in intravascular imaging. Russian Journal of Cardiology and Cardiovascular Surgery. 2024; 17 (1): 77‑81. (In Russ.). https://doi.org/10.17116/kardio20241701177.

5. Guglielmo Gallone, Matteo Bellettini, Marco Gatti, Davide Tore et al., Coronary Plaque Characteristics Associated With Major Adverse Cardiovascular Events in Atherosclerotic Patients and Lesions: A Systematic Review and Meta-Analysis. JACC Cardiovascular Interventions 2023;16(12):1584-1604. https://doi.org/10.1016/j.jcmg.2023.08.006.

6. Ziad A Ali, Keyvan Karimi Galougahi, Susan V Thomas, Arsalan Abu-Much et al., Optical Coherence Tomography-Guided Percutaneous Coronary Intervention: Practical Application. Interventional Cardiology Clinics 2023 12(2): 215-224. https://doi.org/10.1016/j.iccl.2022.12.003.

7. Do-Yoon Kang, Jung-Min Ahn, Sung-Cheol Yun, Seung-Ho Hur et al., Optical Coherence Tomography-Guided or Intravascular Ultrasound-Guided Percutaneous Coronary Intervention: The OCTIVUS Randomized Clinical Trial. Circulation 2023 17;148(16):1195-1206. https://doi.org/10.1161/CIRCULATIONAHA.123.066429.

8. Daniel A Jones, Krishnaraj S Rathod, Sudheer Koganti, Stephen Hamshere et al. Angiography Alone Versus Angiography Plus Optical Coherence Tomography to Guide Percutaneous Coronary Intervention: Outcomes From the Pan-London PCI Cohort. JACC Cardiovasc Interv., 2018; 11(14): 1313-1321, https://doi.org/10.1016/j.jcin.2018.01.274.

9. Joo Myung Lee, Ki Hong Choi, Young Bin Song, Jong-Young Lee et al., Intravascular Imaging–Guided or Angiography-Guided Complex PCI. New England Journal of Medicine 2023;388:1668-1679. https://doi.org/10.1056/NEJMoa2216607.

10. Francesco Prati, Enrico Romagnoli, Laura Gatto, Alessio La Manna, Francesco Burzotta et al., Relationship between coronary plaque morphology of the left anterior descending artery and 12 months clinical outcome: the CLIMA study. European Heart Journal 2020; 41(3): 383-391, https://doi.org/10.1093/eurheartj/ehz520.

11. Elvin Kedhi, Balazs Berta, Tomasz Roleder, Renicus S Hermanides et al., Thin-cap fibroatheroma predicts clinical events in diabetic patients with normal fractional flow reserve: the COMBINE OCT–FFR trial. European Heart Journal 2021 42(45)1: 4671–4679. https://doi.org/10.1093/eurheartj/ehab433.

12. Lorenz Räber, Konstantinos C Koskinas, Kyohei Yamaji, Masanori Taniwaki et al., Changes in Coronary Plaque Composition in Patients With Acute Myocardial Infarction Treated With High-Intensity Statin Therapy (IBIS-4): A Serial Optical Coherence Tomography Study. JACC: Cardiovascular Imaging 2019;12(8)1: 1518-1528. https://doi.org/10.1016/j.jcmg.2018.08.024

13. Prof David Erlinge, Prof Akiko Maehara, Prof Ori Ben-Yehuda, Prof Hans Erik Bøtker et al., Identification of vulnerable plaques and patients by intracoronary near-infrared spectroscopy and ultrasound (PROSPECT II): a prospective natural history study. Lancet 2021; 397: 985–995. https://doi.org/10.1016/S0140-6736(21)00249-X.

14. Kazumasa Kurogi, Masanobu Ishii, Nobuyasu Yamamoto, Kenshi Yamanaga et al. Optical coherence tomography-guided percutaneous coronary intervention: a review of current clinical applications. Cardiovasc Interv Ther., 2021; 36(2): 169-177, https://doi.org/10.1007/s12928-020-00745-4.

15. Eisuke Usui, Taishi Yonetsu, Yoshihisa Kanaji, Masahiro Hoshino, Masao Yamaguchi et al., Efficacy of Optical Coherence Tomography-derived Morphometric Assessment in Predicting the Physiological Significance of Coronary Stenosis: Head-to-Head Comparison with Intravascular Ultrasound. EuroIntervention 2018 13 (18): 2210-2218. https://doi.org/10.4244/EIJ-D-17-00613.

16. Gregg W Stone, Akiko Maehara, Ziad A Ali, Claes Held, Mitsuaki Matsumura et al., Percutaneous Coronary Intervention for Vulnerable Coronary Atherosclerotic Plaque. Journal of the American College of Cardiology 2020 17; 76 (20): 2289-2301. https://doi.org/10.1016/j.jacc.2020.09.547.

17. Seung-Jung Park, Jung-Min Ahn, Do-Yoon Kang, Sung-Cheol Yun et al., Preventive percutaneous coronary intervention versus optimal medical therapy alone for the treatment of vulnerable atherosclerotic coronary plaques (PREVENT): a multicentre, open-label, randomised controlled trial. The Lancet 2024 4;403(10438):1753-1765. https://doi.org/10.1016/S0140-6736(24)00413-6

18. Akchurin R. S., Alekyan B. G., Alekhin M. N., Aronov D. M., Clinical practice guidelines for Stable coronary artery disease. Russian Society of Cardiology 2024; 29 (9): 6110 (In Russ.). https://doi.org/10.15829/1560-4071-2024-6110.

19. Virmani R., Kolodgie F.D., Burke A.P., Farb A., et al., Lessons from sudden coronary death: a comprehensive morphological classification scheme for atherosclerotic lesions. Arteriosclerosis, Thrombosis and Vascular Biology 2000 20: 1262–1275. https://doi.org/10.1161/01.atv.20.5.1262.