More than 25 percent of patients with acute coronary syndromes (ACS) who are normally treated with stents may be able to forgo this procedure and receive anti-thrombotic medications only, according to results of the EROSION pilot study presented Aug. 30 during ESC Congress 2016 in Rome, and simultaneously published in the European Heart Journal.

The study used optical coherence tomography (OCT) to differentiate plaque erosion from plaque rupture among 405 ACS patients presenting at the emergency department and undergoing coronary angiography. Plaque erosion was identified as the underlying pathology in 103 (25.4 percent) patients, of whom 60 had a residual diameter stenosis of less than 70 percent on angiogram, Thrombolysis In Myocardial Infarction (TIMI) flow grade of three, and were stable without symptoms. These patients received anti-thrombotic medications alone without stent placement and were treated with dual antiplatelet therapy (DAPT) (aspirin and ticagrelor). Additionally, 63.6 percent of these patients received a glycoprotein IIb/IIIa inhibitor.

At one month follow-up, 47 of the 60 patients (78.3 percent) met the primary endpoint of a more than 50 percent reduction in the size of their clot. Twenty two patients had no visible clot at all. Overall, clot volume decreased from 3.7 to 0.2 mm³ and minimal flow area increased from 1.7 to 2.1 mm². One patient died of gastrointestinal bleeding while on DAPT and another one had no improvement in the stenotic artery at one month, with the decision to undergo percutaneous coronary intervention.

“Currently all patients with ACS are uniformly treated with stenting regardless of underlying pathology. This study, for the first time, demonstrates that patients with ACS caused by erosion may benefit from a tailored therapy with anti-thrombotic medications,” said lead investigator Ik-Kyung Jang, MD, PhD, FACC, from Harvard Medical School, Massachusetts General Hospital in Boston. “If we can identify ACS patients with erosion without an invasive procedure, those patients may be triaged to a conservative therapy pathway instead of invasive catheterization and stent implantation.”

“Due to the relatively small sample size, this study should be replicated in a larger trial before this is considered for standard therapy,” said Kim A. Eagle, MD, MACC, editor in chief of ACC.org.

Keywords: ESC Congress, Acute Coronary Syndrome, Plaque, Atherosclerotic, Stents, Thrombosis, Angiography

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