The randomized study of preventive revascularization of vulnerable coronary artery plaques in patients with stable coronary artery disease

Background. Today, a number of unresolved issues remain regarding vulnerable coronary plaques, one of which is the need for preventive revascularization.
Aim. Evaluation of the appropriateness of preventive revascularization of functionally insignificant lesions of the coronary arteries with signs of vulnerability according to the virtual histology of intravascular ultrasound in patients with stable coronary artery disease.
Methods. The prospective randomized study includes patients with stable coronary artery disease and isolated intermediate-grade coronary stenosis. The first step in patients is measured fractional flow reserve to confirm the hemodynamic insignificance of stenosis. Then an intravascular ultrasound is performed to verify signs of plaque vulnerability: a thin-cap fibroatheroma and / or minimum lumen area <4 mm² and/or plaque burden >70%. After that, patients are randomized into two groups: preventive revascularization or optimal medical therapy. After 12 months, patients undergo repeated intravascular ultrasound and end-point analysis.
Results. So far, 10 patients have been included in the study (6 in the preventive revascularization group and 4 in the optimal medical therapy group). No endpoints and complications were recorded in both groups in 30-days follow-up.
Conclusion. Intravascular imaging methods can identify vulnerable coronary plaques, which allows you to use a personalized approach in determining treatment tactics, one of which can be preventive revascularization.

1. Bom MJ, van der Heijden DJ, Kedhi E, van der Heyden J, Meuwissen M, Knaapen P, Timmer SAJ, van Royen N. Early Detection and Treatment of the Vulnerable Coronary Plaque: Can We Prevent Acute Coronary Syndromes? Circ Cardiovasc Imaging. 2017. 10 (5). pii: e005973. doi: 10.1161/CIRCIMAGING.116.005973

2. Papaioannou TG, Kalantzis C, Katsianos E, Sanoudou D, Vavuranakis M, Tousoulis D. Personalized Assessment of the Coronary Atherosclerotic Arteries by Intravascular Ultrasound Imaging: Hunting the Vulnerable Plaque. J Pers Med. 2019 9(1). pii: E8. doi: 10.3390/jpm9010008

3. Kochergin N.A., Kochergina A.M. Intravascular Ultrasound Studies and the Vulnerable Atherosclerotic Plaque (Literature Review). Medical visualization. 2017. 21 (4): 82–87. (in Russian). doi: 10.24835/1607-0763-2017-4-82-87

4. Kaul S, Diamond GA. Improved prospects for IVUS in identifying vulnerable plaques? JACC Cardiovasc Imaging. 2012. 5 (3): S106-10. doi: 10.1016/j.jcmg.2012.02.00

5. Calvert PA, Obaid DR, O'Sullivan M, Shapiro LM, McNab D, Densem CG, Schofield PM, Braganza D, Clarke SC, Ray KK, West NE, Bennett MR. Association between IVUS findings and adverse outcomes in patients with coronary artery disease: the VIVA (VH-IVUS in Vulnerable Atherosclerosis) Study. JACC Cardiovasc Imag 2011; 4: 894-901. doi: 10.1016/j.jcmg.2011.05.005

6. Cheng JM, Garcia-Garcia HM, de Boer SP, Kardys I, Heo JH, Akkerhuis KM, Oemrawsingh RM, van Domburg RT, Ligthart J, Witberg KT, Regar E, Serruys PW, van Geuns RJ, Boersma E.In vivo detection of high-risk coronary plaques by radiofrequency intravascular ultrasound and ardiovascular outcome: results of the ATHEROREMO-IVUS study. Eur Heart J 2014; 35: 639-647. doi: 10.1093/eurheartj/eht484

7. Kochergin N.A., Kochergina A.M., Ganjukov V.I., Barbarash O.L. Vulnerable atherosclerotic plaques of coronary arteries in patients with stable coronary artery disease. Complex Issues of Cardiovascular Diseases. 2018; 7 (3): 65-71. (in Russian). doi: 10.17802/2306-1278-2018-7-3-65-71

8. Xaplanteris P, Fournier S, Pijls NHJ, Fearon WF, Barbato E, Tonino P, et al. FAME 2 Investigators. Five-Year Outcomes with PCI Guided by Fractional Flow Reserve. N Engl J Med. 2018. 379(3):250-259. doi: 10.1056/NEJMoa1803538.

9. Sinclair H1, Veerasamy M, Bourantas C, Egred M, Nair A, Calvert PA, Brugaletta S, Mintz GS, Kunadian V. The Role of Virtual Histology Intravascular Ultrasound in the Identification of Coronary Artery Plaque Vulnerability in Acute Coronary Syndromes. Cardiology in Review 2016; 24(6): 303-309, doi: 10.1097/CRD.0000000000000100

10. Kataoka Y, Wolski K, Balog C, Uno K, Puri R, Tuzcu EM, Nissen SE, Nicholls SJ. Progression of coronary atherosclerosis in stable patients with ultrasonic features of high-risk plaques. Eur Heart J Cardiovasc Imaging. 2014;15:1035–1041. doi: 10.1093/ehjci/jeu065

11. Komukai K, Kubo T, Kitabata H, Matsuo Y, Ozaki Y, Takarada S, et al. Effect of atorvastatin therapy on fibrous cap thickness in coronary atherosclerotic plaque as assessed by optical coherence tomography: the EASY-FIT study. J Am Coll Cardiol. 2014;64:2207–2217. doi: 10.1016/j.jacc.2014.08.045

12. Tsujita K, Sugiyama S, Sumida H, Shimomura H, Yamashita T, Yamanaga K, et al; PRECISE–IVUS Investigators. Impact of Dual Lipid-Lowering Strategy With Ezetimibe and Atorvastatin on Coronary Plaque Regression in Patients With Percutaneous Coronary Intervention: The Multicenter Randomized Controlled PRECISE-IVUS Trial. J Am Coll Cardiol. 2015;66:495–507. doi: 10.1016/j.jacc.2015.05.065

13. Cheng JM, Oemrawsingh RM, Garcia-Garcia HM, Boersma E, van Geuns RJ, Serruys PW, Kardys I, Akkerhuis KM. PCSK9 in relation to coronary plaque inflammation: Results of the ATHEROREMO-IVUS study. Atherosclerosis. 2016;248:117–122. doi: 10.1016/j.atherosclerosis.2016.03.010

14. Kuroda M, Shinke T, Sakaguchi K, Otake H, Takaya T, Hirota Y, et al. Effect of daily glucose fluctuation on coronary plaque vulnerability in patients pre-treated with lipid-lowering therapy: a prospective observational study. JACC Cardiovasc Interv. 2015. 8(6):800-811. doi: 10.1016/j.jcin.2014.11.025