Preventive PCI of non-flow-limiting plaque was linked to benefit only when the plaque was lipid-rich

Design

Post hoc analysis of an open-label, multicentre randomised trial

Population

598 patients with 632 non-flow-limiting high-burden lesions imaged by NIRS-IVUS

Primary outcome

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

Effect

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

PREVENT randomised 1606 patients with non-flow-limiting (FFR above 0.80) but high-risk plaques to preventive PCI plus medical therapy or medical therapy alone. This post hoc analysis took the 598 patients whose lesions had plaque burden above 70% and minimal lumen area below 4 mm² on intravascular ultrasound and who also had near-infrared spectroscopy. A maximum lipid core burden index above 315 over 4 mm defined lipid-rich plaque, found in 37.3%.

Over a median of 5.6 years, lipid-rich lesions carried more events (12.5% vs 4.7%). Within that group, preventive PCI was associated with fewer events than medical therapy alone (7.3% vs 17.6%; adjusted HR 0.23, 0.13–0.41). In lipid-poor lesions there was no difference (5.5% vs 4.2%; HR 1.00), despite equally large plaque burden and small lumens. The interaction was significant.

This is a subgroup of an open-label trial, and the comparison within each group is not randomised in the way the main trial was. It strengthens the argument that plaque composition, not just size, should guide any future preventive PCI, but it is a hypothesis for a dedicated trial rather than a reason to stent lipid-rich lesions now.

• Plaque size and lumen area alone did not identify lesions that gained from preventive PCI in this analysis.
• Near-infrared spectroscopy is not widely available; this finding cannot yet be applied in most cath labs.
• Intensive lipid lowering and antiplatelet therapy remain the treatment for non-flow-limiting plaque.
• Treat this as hypothesis-generating until a trial randomises on lipid content.

Why it matters

It suggests the useful question about a non-flow-limiting plaque is what it is made of, not how big it is.

Don't overread it

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

The statistics, in plain English

A hazard ratio of 0.23 looks large, but it comes from a post hoc subgroup of 223 patients, and large effects in subgroups often shrink when tested directly. The significant interaction makes chance less likely as an explanation, but does not remove confounding from which lesions had spectroscopy done.

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