Preventive PCI was linked to benefit only in lipid-rich plaques

Design

Post hoc analysis of an open-label multicentre randomised trial

Population

598 patients with 632 non-flow-limiting high-burden lesions imaged by near-infrared spectroscopy

Primary outcome

Cardiac death, target-vessel MI, ischaemia-driven revascularisation or angina admission

Effect

Lipid-rich plaque: 7.3% vs 17.6%, adjusted HR 0.23 (0.13–0.41); other lesions HR 1.00 (0.54–1.86)

PREVENT randomised 1,606 patients with non-flow-limiting but high-risk coronary lesions to preventive PCI or medical therapy. This post hoc analysis took the 598 patients who also had near-infrared spectroscopy, all with lesions showing plaque burden above 70% and a minimal lumen area under 4 mm² on intravascular ultrasound. A lipid core burden index above 315 defined a lipid-rich plaque, present in 37.3%.

Over a median 5.6 years, lipid-rich plaques carried more events (12.5% vs 4.7%). Within that group, preventive PCI was associated with fewer events than medical therapy (7.3% vs 17.6%; adjusted HR 0.23, 0.13–0.41). In lesions without a lipid-rich core, there was no difference (HR 1.00).

This is a post hoc subgroup of an open-label trial, using an imaging modality few laboratories have. It suggests plaque composition may matter more than size, but it is a hypothesis for the next trial, not a reason to stent non-ischaemic lesions.

• Do not stent non-flow-limiting lesions on this analysis outside a trial or protocol
• Continue intensive lipid lowering and antiplatelet therapy for high-risk plaque regardless of anatomy
• Note that near-infrared spectroscopy is not widely available in Indian cath labs
• Watch for prospective trials that randomise by plaque composition

Why it matters

It challenges the idea that plaque size alone identifies the lesion that will cause the next event.

Don't overread it

A post hoc subgroup of an open-label trial cannot establish that stenting lipid-rich plaques prevents events.

The statistics, in plain English

An adjusted hazard ratio of 0.23 looks dramatic, but subgroup findings found after a trial ends are often smaller or absent when tested properly. The significant interaction test strengthens the signal somewhat; it does not make it proof.

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