In patients with lipid-rich plaques (LRPs) defined by near-infrared spectroscopy (NIRS), preventive PCI was associated with lower cardiovascular risk, yet no significant association was observed in patients with non-LRPs despite their large plaque burden and small minimal lumen area, according to results from a post hoc analysis of the PREVENT trial published Oct. 6 in Circulation.

The investigator-initiated, randomized, open-label PREVENT trial enrolled 1,606 patients across 15 centers in South Korea, Japan, Taiwan and New Zealand from September 2015 to September 2021.

Seong-Bong Wee, MD, Seung-Jung Park, MD, PhD, FACC, et al., included 598 patients from the parent trial in this analysis. The analysis comprised 632 lesions with a plaque burden >70% and a minimal lumen area <4 mm² by IVUS that also underwent NIRS. Patients had a mean age of 64 years, and nearly one-third were women. LRPs were present in 223 patients (37%) with 234 lesions.

Researchers prespecified an LRP as having a maximum lipid core burden index over a 4-mm segment >315 and defined the primary outcome as a composite of death from cardiac causes, target-vessel myocardial infarction, ischemia-driven target-vessel revascularization or hospitalization for unstable or progressive angina.

During a median follow-up of 5.6 years, primary outcome events occurred more frequently in patients with LRPs vs. non-LRPs (13% vs. 5%) in the overall population (hazard ratio [HR], 2.08; p=0.039).

In the LRP group, compared with optimal medical therapy alone, preventive PCI was associated with a lower risk of the primary outcome (7% vs. 18%; adjusted HR, 0.23; p<0.001). In the non-LRP group, no benefit of preventive PCI was observed (6% vs. 4%; adjusted HR, 1.00; p=0.97). Notably, a significant interaction was found between treatment strategy and the presence of LRP (P_interaction<0.001).

"These findings highlight the importance of the synergistic utility of characterizing plaque composition along with morphology in guiding preventive PCI decisions," write the authors, emphasizing that their results support "the rationale for prospective trials evaluating NIRS-derived LCBI-guided preventive PCI strategies."