Preventive PCI was linked to fewer events only in lipid-rich plaques

Design

Post hoc analysis of an open-label randomised trial (PREVENT)

Population

598 patients with 632 non-flow-limiting lesions, plaque burden above 70%, assessed by IVUS and NIRS

Primary outcome

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

Effect

Lipid-rich plaques: 7.3% vs 17.6% with PCI vs medical therapy (adjusted HR 0.23, 0.13–0.41); others: HR 1.00 (0.54–1.86)

PREVENT randomised patients with non-flow-limiting but high-risk coronary plaques (FFR above 0.80) to preventive PCI or optimal medical therapy. This post hoc analysis, published in Circulation on 6 October, looked at 598 of them whose lesions had a plaque burden above 70% and a small lumen area on intravascular ultrasound, and who also had near-infrared spectroscopy (NIRS).

About 37% had a lipid-rich plaque by a prespecified NIRS threshold. Over a median 5.6 years, those patients had more events (12.5% vs 4.7%). Within the lipid-rich group, preventive PCI was associated with fewer events than medical therapy alone (7.3% vs 17.6%). In plaques that were large and tight but not lipid-rich, PCI made no difference.

The finding suggests composition, not just size, marks the plaques worth treating. But it is a post hoc subgroup of an open-label trial, using an imaging tool few laboratories have. It is a hypothesis for the next trial, not a reason to stent non-ischaemic lesions.

• Optimal medical therapy remains the standard for non-flow-limiting lesions; this analysis does not change that.
• Large, tight plaques without a lipid-rich core did not benefit from preventive PCI.
• NIRS-defined lipid-rich plaque identified a higher-risk group, worth intensive lipid lowering.
• Treat this as a research signal pending a dedicated trial.

Why it matters

It shifts the vulnerable-plaque debate from how big a lesion is to what it contains.

Don't overread it

This is a post hoc subgroup of an open-label trial; it cannot establish that preventive PCI helps lipid-rich plaques.

The statistics, in plain English

An adjusted hazard ratio of 0.23 (95% CI 0.13 to 0.41) would mean a large reduction, but subgroups chosen after a trial ends often show effects that shrink on replication. The interaction test is what supports a real difference between lipid-rich and other plaques, and even that needs confirming prospectively.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.