Maximum Lipid Core Burden Index Research Articles

Intracoronary Near-Infrared Spectroscopy to Predict No-Reflow Phenomenon During Percutaneous Coronary Intervention in Acute Coronary Syndrome

Near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) can identify the lipid-rich lesions, described as high lipid-core burden index (LCBI). The aim of this study was to investigate the relationship between lipid core plaque (LCP) in the infarct-related lesion detected using NIRS-IVUS and no-reflow phenomenon during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). We investigated 371 ACS patients who underwent NIRS-IVUS in the infarct-related lesions before PCI. The extent of LCP in the infarct-related lesion was calculated as the maximum LCBI for each of the 4-mm longitudinal segments (maxLCBI4mm) measured by NIRS-IVUS. The patients were divided into 2 groups using a maxLCBI4mm cut-off value of 400. The overall incidence of no-reflow phenomenon was 53/371 (14.3%). No-reflow phenomenon was more frequently occurred in patients with maxLCBI4mm ≥400 compared to those with maxLCBI4mm <400 (17.5% vs. 2.5%, p<0.001). After propensity score matching, multivariable logistic regression analysis demonstrated that maxLCBI4mm (odds ratio: 1.008; 95% confidence interval: 1.005 - 1.012, p<0.001) was independently associated with no-reflow phenomenon. The maxLCBI4mm of 719 in the infarct-related lesion had the highest combined sensitivity (69.8%) and specificity (72.1%) for the identification of no-reflow phenomenon. In conclusion, in patients with ACS, maxLCBI4mm in the infarct-related lesion assessed by NIRS-IVUS was independently associated with no-reflow phenomenon during PCI.

The accuracy of detailed analysis of optical coherence tomography in detection of plaque lipid content: dual-imaging study with optical coherence tomography and near-infrared spectroscopy

Background Lipid-rich plaque covered by a thin fibrous cap (FC) has been identified as a frequent morphological substrate for the development of acute coronary syndrome. Optical coherence tomography (OCT) permits the identification and measurement of the FC. Near-infrared spectroscopy (NIRS) has been approved for detection of coronary lipids. Aims We aimed to assess the ability of detailed OCT analysis to identify coronary lipids, using NIRS as the reference method. Methods In total, 40 patients with acute coronary syndrome underwent imaging of a non-culprit lesion by both NIRS and OCT. For each segment, the NIRS-derived 4 mm segment with maximal lipid core burden index (maxLCBI4mm) was assessed. OCT analysis was performed using a semi-automated method including measurement of the fibrous cap thickness (FCT) of all detected fibroatheromas. Subsequent quantitative volumetric evaluation furnished FCT, FC surface area (FC SA), lipid arc, and FC (fibrous cap) volume data. OCT features of lipid plaques were compared with maxLCBI4mm. Predictors of maxLCBI4mm >400 was assessed by using univariable and multivariable analysis. Results OCT features (mean FCT, total FC SA, FC volume, maximal, mean, and total lipid arcs) strongly correlated with the maxLCBI4mm (p = 0.012 for the mean FCT, respectively p < 0.001 for all other aforementioned features). The strongest predictors of maxLCBI4mm >400 were the maximal (p = 0.002) and mean (p = 0.002) lipid arc, and total FC SA (p = 0.012). Conclusions We found a strong correlation between the OCT-derived features and NIRS findings. Detailed OCT analysis may be reliably used for detection of the presence of coronary lipids.

Thin Calcification Predicts Lipid Component in Carotid Plaque—Relationship Between Lipid Distribution and Thin Calcification

BackgroundAccurately evaluating plaque characteristics is essential because lesions with lipid-rich plaque put patients at risk of thromboembolic complications from carotid artery stenting (CAS). Near-infrared spectroscopy (NIRS) is a diagnostic imaging modality that identifies lipid components from the near-infrared absorption pattern, but does not reveal the distribution of calcification. The purpose of this study was to investigate the calcification characteristics of unstable carotid plaques, focusing on relationships between the calcification characteristics revealed by computed tomography angiography (CTA) and the lipid core distribution derived from NIRS. MethodsParticipants in this retrospective analysis comprised 35 patients (29 men, 6 women; mean age, 76.0 years; range, 52–89 years) who underwent CAS in our institute between January 2021 and December 2022. We evaluated the thickness and length of carotid calcifications at the minimal lumen level from preoperative CTA and analyzed the relationship with maximal lipid core burden index (max-LCBI) from NIRS. ResultsStrong, negative linear correlations were observed between the thickness of calcification and max-LCBI at Area (any segment in a target lesion) (r=-0.795, p<0.001), max-LCBI at minimal lumen area (MLA) (r=-0.795, p<0.001) and LCBI at Lesion (rate of LCBI in entire plaque lesion) (r=-0.788, p<0.001), respectively. Significant negative linear correlations were observed between distribution of calcification length and max-LCBI at Area (r=-0.429, p=0.01), max-LCBI at MLA (r=-0.373, p=0.027) and LCBI at Lesion (r=-0.443, p=0.008). ConclusionsThin and ubiquitous carotid calcification was associated with LCBI values derived from NIRS indicative of carotid lipid plaque distribution, implying the possibility of predicting lesion instability.

Lowering apolipoprotein C-III associates with regression of lipidic plaque materials in type 2 DM patients with coronary artery disease: the pre-specified analysis from the OPTIMAL trial

Abstract Introduction Apolipoprotein CIII (ApoC-III) is a circulating lipoprotein which affects triglyceride-rich lipoprotein metabolism and functionality of high-density lipoproteins. These properties indicate ApoC-III as a potential contributor to atherosclerosis. The OPTIMAL randomized controlled trial (jRCT1052180152) compared the efficacy of continuous glucose monitoring guided versus HbA1c-guided glycemic control on coronary atherosclerosis in Type 2 Diabetes (T2DM) patients by using serial near-infrared spectroscopy/intravascular ultrasound (NIRS/IVUS). Given that NIRS/IVUS imaging enables to quantitatively evaluate plaque burden and its lipidic component in vivo, the OPTIMAL study provides an opportunity to elucidate the association of ApoC-III with change in quantity and quality of coronary plaques. Purpose To elucidate whether serial change in ApoC-III affects the degree of atheroma progression and lipidic plaque materials on NIRS/IVUS imaging. Methods The OPTIMAL trial has serially monitored non-culprit lesions in 94 T2DM patients receiving PCI by NIRS/IVUS imaging. Of these, 46 patients (73 lesions) were included into the current analysis. Circulating ApoC-III levels were measured at both baseline and 48 weeks. The relationships of serial change in ApoC-III with NIRS/IVUS-derived measures [total atheroma volume (TAV) and maximum lipid core burden index in a 4-mm segment (maxLCBI4mm)] were analyzed. Results All of study subjects received a statin, and high-intensity statin was used in 65.2% of them. On-treatment LDL-C and HbA1c levels were 1.9±0.5mmol/L and 7.2±0.7%, respectively. On NIRS/IVUS analysis, any regression of TAV and maxLCBI4mm was observed in 71.2 and 38.4% of analyzed lesions, respectively (Table). There was no significant relationship between change in ApoC-III and TAV regression (r=0.02, p=0.89). However, a reduction of ApoC-III was significantly associated with a greater regression of maxLCBI4mm (r=0.26, p=0.03) (Figure). Furthermore, multivariate analysis adjusting for LDL-C and high-intensity statin use demonstrated lowering ApoC-III level as an independent predictor of maxLCBI4mm regression (OR=0.83, 95%CI=0.69-0.99, p=0.04) (Table). Even in patients receiving high-intensity statin, the relationship of change in ApoC-III with regression of maxLCBI4mm still existed (Figure). Conclusion Serial NIRS/IVUS imaging revealed that a reduction of circulating ApoC-III was associated with a greater regression of maxLCBI4mm. Our findings suggest ApoC-III as an important therapeutic target to modulate lipidic plaque materials in T2DM receiving a statin.Tables

Lipid core burden in relation to the severity of calcium burden assessed by computed tomographic coronary angiography in patients with chronic coronary syndrome

Abstract Background Coronary calcium scores (CACS) obtained by computed tomographic coronary angiography (CTCA) enables a noninvasive assessment of coronary calcium burden both in a single vessel and in whole coronary tree. Although higher CACS in coronary tree is known as an atherosclerotic cardiovascular disease risk marker, coronary calcification is also known as a sign of plaque stabilization. Exploring the relationship between coronary calcification and lipid core burden may help understanding a role of calcium in coronary tree. Purpose We aimed to examine the relevance of lipid components assessed by near-infrared spectroscopy (NIRS) in accordance with different degrees of CACS assessed by preprocedural CTCA imaging. Methods We investigated consecutive patients who underwent elective percutaneous coronary intervention (PCI) and pre-PCI CTCA imaged within 3 months before PCI. Patients who had stents in target vessels and who required plaque modification before NIRS imaging were excluded. Target vessels were divided into tertiles based on target vessel CACS (CACSv) and total amount of 3-vessel CACS (CACSt), respectively. Lipid components of the target vessel were evaluated by maximum lipid core burden index in 4mm (maxLCBI4mm). MaxLCBI4mm was compared among the tertiles of CACSv and CACSt. Results A total of 95 target vessels in 95 patients were evaluated for the final dataset. CACSv categories were defined as follows: 1st tertile (CACSv &amp;lt;66), 2nd tertile (CACSv &amp;gt;66 and &amp;lt;250), and 3rd tertile (CACSv &amp;gt;250). CACSt categories were defined as showing CACSt &amp;lt;190 (1st tertile), CACSt &amp;gt;190 and &amp;lt;700 (2nd tertile), and CACSt &amp;gt;700 (3rd tertile). MaxLCBI4mm increased in proportion to an extent of CACv tertiles (306 [129-463], 280 [125-460], and 444 [345-587], Ptrend &amp;lt;0.01) and an extent of CACt tertiles (265 [99-488], 356 [202-458], and 448 [318-574], Ptrend &amp;lt;0.01). Conclusions In patients who underwent elective PCI, higher maxLCBI4mm in the PCI target vessel was associated with both higher CACS in the target vessel and total amount of 3-vessel CACS.

Predictors of residual lipid content detected by near-infrared spectroscopy after elective stenting in patients with chronic coronary syndrome

Abstract Backgrounds Residual lipid-rich plaque (LRP) in stented segments assessed by near-infrared spectroscopy (NIRS) immediately after percutaneous coronary intervention (PCI) is reportedly associated with target lesion failure. However, morphological determinants of residual LRP after elective PCI remains unknown. Purpose This single-center observational study aimed to explore morphological and procedural predictors of residual LRP after electing PCI. Methods We investigated 340 consecutive patients who underwent elective NIRS-intravascular ultrasound-guided PCI for de novo coronary lesions. Lesions requiring balloon dilatation or debulking before NIRS imaging, requiring ≥2 remote stent deployment in the vessel, being treated with drug-coated balloon, and having insufficient NIRS imaging were excluded. Maximum lipid core burden index in 4mm (maxLCBI4mm) in culprit segment both before and after PCI was assessed by NIRS. Residual LRP was defined as post-PCI maxLCBI4mm in stented lesions &amp;gt;200. Baseline clinical and morphological findings were compared between lesions with versus without residual LRP. Multivariable logistic regression analysis was performed to determine predictors of residual LRP. Results A total of 236 de novo lesions in 223 patients were included in the final dataset. After PCI, residual LRP was observed in 69 (29%) lesions. Patients with residual LRP tended to be older than those without residual LRP. Pre-PCI maxLCBI4mm in culprit lesions, plaque burden, and remodeling index were greater in lesions with residual LRP. Post-PCI minimum stent area and expansion index tended to be smaller in lesions with residual LRP. In a multivariable analysis, pre-PCI maxLCBI4mm (per 10, adjusted odds ratio [OR]:1.04; 95% confidence interval [CI]: 1.02 to 1.05; p&amp;lt;0.01) and stent expansion index (per 10%, adjusted OR: 0.80; 95%CI: 0.64 to 0.99; p=0.047) were independently predictive of residual LRP. Conclusions In patients undergoing elective PCI, greater pre-PCI maxLCBI4mm and smaller stent expansion were associated with post-PCI residual LRP.

Frequency, predictors and clinical outcomes of AMI patients with triple regression of coronary atherosclerosis: A sub-analysis of the PACMAN AMI trial

Abstract Background Recent studies have shown that coronary artery disease regression is not limited to atheroma reduction but also includes plaque stabilization in patients treated with high-intensity lipid-lowering therapy. The frequency and characteristics of patients who simultaneously show atheroma volume reduction and plaque stabilization defined as reduction in plaque lipid content and increase in fibrous cap thickness (i.e., triple regression) are unknown. Purpose This study sought to determine the percentage and determinants of both plaque volume reduction and plaque stabilization in patients with acute myocardial infarction (MI) and treated wiTh alirocumab or placebo added to high-intensity statin therapy. Methods The PACMAN-AMI trial employed serial intravascular ultrasound, near-infrared spectroscopy and optical coherence tomography to compare the effects of alirocumab vs. placebo (1:1) in 265 patients (537 non–infarct-related coronary arteries) receiving high-intensity statin therapy. Triple regression was defined by the combined presence of reduction in percent atheroma volume (PAV), reduction in maximum lipid core burden index (maxLCBI4mm) and increase in minimal fibrous cap thickness (FCT). Clinical outcomes of patients with or without triple regression were assessed at one year follow-up. Results Overall, 199 (75.1%) patients showed PAV reduction, 180 (67.7%) maxLCBI4mm reduction and 172 (77.6%) minimal FCT increase, with a total of 84 (31.7%) patients having triple regression (40.8% in the alirocumab group vs. 23.0% in the placebo group, p=0.002). The percentage of patients with triple regression was similar among the groups with PAV reduction, maxLCBI4mm reduction or minimal FCT thickening (42%, 51% or 49%, respectively, p=0.30). Similar baseline clinical features and a higher reduction in low-density lipoprotein cholesterol (LDL-C, -27.1 [37.7 to -16.6] mg/dl, p&amp;lt;0.001) and apolipoprotein B levels (-18.5 [-26.0 to -11.0] p&amp;lt;0.001) were observed patienst with vs. without triple regression. A higher reduction in PAV (-1.54 [-2.14 to -0.95] %, p&amp;lt;0.001), maxLCBI4mm (-111.24 [-140.46 to -82.02], p&amp;lt;0.001) and a higher increase in minimal FCT (56.39 [38.67 to 74.11] µm, p&amp;lt;0.001) were found in patients with triple regression. At multivariable analysis, factors independently associated with triple regression included higher baseline maxLCBI4mm (1.03, 1.01 to 1.06, p=0.013) and alirocumab treatment (2.83, 1.57 to 5.16, p=0.001). The composite clinical endpoint of death, MI and ischemia-driven revascularization occurred less frequently in patients with versus without triple regression (8.3% vs 18.2%, p=0.042). Conclusions Triple regression occurred among one third of acute AMI patients receiving high-intensity lipid lowering therapy. Alirocumab treatment and higher baseline lipid accumulation were independent predictors of triple regression. Triple regression was associated with a reduced rate of adverse cardiovascular events.

Bailout inclisiran-based triple lipid-lowering therapy reduces plaque lipid content in stable coronary artery disease patients

Abstract Background Low-density lipoprotein cholesterol (LDL-C) has a causal role in atherosclerotic cardiovascular disease. Genetic studies and variability in individual response to lipid-lowering therapies suggest combining hypolipidaemic medications with different mechanisms of action. Purpose The aim of this study was to evaluate the effect of triple inclisiran-based hypolipidaemic therapy in patients not reaching LDL-C target on maximum statin/ezetimibe treatment. Methods This prospective study enrolled 37 stable coronary artery disease patients admitted for elective percutaneous coronary intervention after 4-6 weeks on maximum tolerated statin and/or ezetimibe therapy during run-in period. Afterwards, patients with LDL-C level &amp;gt;1.8 mmol/l at the time of inclusion were assigned to receive add-on inclisiran (triple therapy group). In all participants near-infrared spectroscopy (NIRS) was performed at baseline and after 15 months for atherosclerotic plaque evaluation in the segment of interest, defined as 20-50% lesion in the proximal or middle third of a coronary artery. Statistical analysis was carried out with SPSS Statistics software. Results Average LDL-C level among screened patients was 2.81 (±1.17) mmol/l. In 19 patients LDL-C level remained &amp;gt;1.8 mmol/l on maximally tolerated statin and/or ezetimibe treatment, and after 15 months of triple therapy mean LDL-C reached 1.81 (±1.02) mmol/l with a significant LDL-C percentage change of 35.59% (95%CI -47.31 to -9.18, P=0.006) in this group. 17 patients continued statin/ezetimibe as mono or dual treatment and at 15-month follow-up mean LDL-C level comprised 1.67 (±0.61) mmol/l among these participants. According to NIRS data, maximum lipid-core burden index within 4 mm (maxLCBI4 mm) was significantly reduced by 28.85 (95%CI -189.39 to 17.64, P=0.041) in triple therapy group and by 114.72 in mono or dual therapy group (-194.76 to 23.01, P=0.004), with no statistically significant difference established between both groups (P=0.494). Conclusions Triple therapy demonstrated significant atherosclerotic plaque lipid content reduction along with LDL-C level lowering in patients with insufficient effectiveness of statin/ezetimibe treatment.

Incremental value of physiological indices to predict high-risk plaque detected by NIRS-IVUS

Abstract Background The vulnerable plaque are called high-risk plaques (HRPs), and coronary computed tomography angiography (CCTA) studies have revealed the following characteristics: (1) lesion plaque density on CT≦30HU (2) positive remodeling, (3) The presence of spotty calcification, (4) ΔFractional Flow Reserve derived from CCTA (FFRCT) or Δ Quantitative Flow Reserve (QFR)≧0.06 has been cited as a feature of these lesions. Therefore, identification of HRPs in non-culprit lesion is important to reduce future cardiovascular events. Purpose The purpose of the study was to determine whether HRP is predictable by incremental values of physiological indices in non-culprit lesions of ACS subjects. Methods A total of 137 non-culprit coronary lesions in 31 ACS subjects were retrospectively evaluated by CCTA, FFRCT, QFR and NIRS-IVUS imaging. Each coronary artery was divided into 30mm long segments beginning at the ostium to evaluate lesion vulnerability. By NIRS imaging, plaque with 4-mm maximum lipid-core burden index (maxLCBI4mm) ≥400 was defined as HRP. The relationship between HRP detected by NIRS and CCTA-derived plaque features, delta (Δ) FFRCT, and ΔQFR was evaluated. Results CT density, positive remodeling, diameter stenosis, ΔFFRCT, and ΔQFR were significantly associated with HRP, respectively (P&amp;lt;0.05). On multivariable analysis, CT density (OR; 0.95, 95%CI 0.91-0.99, P=0.0001), diameter stenosis (OR; 1.05, 95%CI 1.00-1.10, P=0.03) and ΔQFR (OR; 2119483 , 95%CI 1.75-2561856632475.6, P=0.03) independently predicted HRP, but not ΔFFRCT. ROC analysis for predicting HRP showed greater accuracy with incremental ΔQFR values in the model of CT density and diameter stenosis (AUC 0.93, P&amp;lt;0.0001). Conclusion HRP detected by NIRS may be predicted with greater accuracy by integrating QFR values with the assessment of CCTA-derived plaque features.figure1figure2

Concomitant Coronary Atheroma Regression and Stabilization in Response to Lipid-Lowering Therapy

BackgroundThe frequency, characteristics, and outcomes of patients treated with high-intensity lipid-lowering therapy and showing concomitant atheroma volume reduction, lipid content reduction, and increase in fibrous cap thickness (ie, triple regression) are unknown. ObjectivesThis study was designed to investigate rates, determinants, and prognostic implications of triple regression in patients presenting with acute myocardial infarction and treated with high-intensity lipid-lowering therapy. MethodsThe PACMAN-AMI (Effects of the PCSK9 Antibody Alirocumab on Coronary Atherosclerosis in Patients with Acute Myocardial Infarction) trial used serial intravascular ultrasound, near-infrared spectroscopy, and optical coherence tomography to compare the effects of alirocumab vs placebo in patients receiving high-intensity statin therapy. Triple regression was defined by the combined presence of percentage of atheroma volume reduction, maximum lipid core burden index within 4 mm reduction, and minimal fibrous cap thickness increase. Clinical outcomes at 1-year follow-up were assessed. ResultsOverall, 84 patients (31.7%) showed triple regression (40.8% in the alirocumab group vs 23.0% in the placebo group; P = 0.002). On-treatment low-density lipoprotein cholesterol levels were lower in patients with vs without triple regression (between-group difference: −27.1 mg/dL; 95% CI: −37.7 to −16.6 mg/dL; P < 0.001). Triple regression was independently predicted by alirocumab treatment (OR: 2.83; 95% CI: 1.57-5.16; P = 0.001) and a higher baseline maximum lipid core burden index within 4 mm (OR: 1.03; 95% CI: 1.01-1.06; P = 0.013). The composite clinical endpoint of death, myocardial infarction, and ischemia-driven revascularization occurred less frequently in patients with vs without triple regression (8.3% vs 18.2%; P = 0.04). ConclusionsTriple regression occurred in one-third of patients with acute myocardial infarction who were receiving high-intensity lipid-lowering therapy and was associated with alirocumab treatment, higher baseline lipid content, and reduced cardiovascular events. (Vascular Effects of Alirocumab in Acute MI-Patients [PACMAN-AMI]; NCT03067844)

Clinical outcomes of acute myocardial infarction arising from non-lipid-rich plaque determined by NIRS-IVUS

Acute myocardial infarction (AMI) can rarely arise from non-lipid-rich coronary plaques. This study sought to compare the clinical outcomes after percutaneous coronary intervention (PCI) between AMI showing maximum lipid-core burden index in 4 mm (maxLCBI4mm) < 400 and ≥ 400 in the infarct-related lesions assessed by near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS). We investigated 426 AMI patients who underwent NIRS-IVUS in the infarct-related lesions before PCI. Major adverse cardiovascular events (MACE) were defined as the composite of cardiac death, non-fatal MI, clinically driven target lesion revascularization (TLR), clinically driven non-TLR, and congestive heart failure requiring hospitalization. 107 (25%) patients had infarct-related lesions of maxLCBI4mm < 400, and 319 (75%) patients had those of maxLCBI4mm ≥ 400. The maxLCBI4mm < 400 group had a younger median age at onset (68 years [IQR: 57–78 years] vs. 73 years [IQR: 64–80 years], P = 0.007), less frequent multivessel disease (39% vs. 51%, P = 0.029), less frequent TIMI flow grade 0 or 1 before PCI (62% vs. 75%, P = 0.007), and less frequent no-reflow immediately after PCI (5% vs. 11%, P = 0.039). During a median follow-up period of 31 months [IQR: 19–48 months], the frequency of MACE was significantly lower in the maxLCBI4mm < 400 group compared with the maxLCBI4mm ≥ 400 group (4.7% vs. 17.2%, P = 0.001). MaxLCBI4mm < 400 was an independent predictor of MACE-free survival at multivariable analysis (hazard ratio: 0.36 [confidence interval: 0.13–0.98], P = 0.046). MaxLCBI4mm < 400 measured by NIRS in the infract-related lesions before PCI was associated with better long-term clinical outcomes in AMI patients.

Preventive PCI or medical therapy alone for vulnerable atherosclerotic coronary plaque: Rationale and design of the randomized, controlled PREVENT trial

Acute coronary syndromes are commonly caused by the rupture of vulnerable plaque, which often appear angiographically not severe. Although pharmacologic management is considered standard therapy for stabilizing plaque vulnerability, the potential role of preventive local treatment for vulnerable plaque has not yet been determined. The PREVENT trial was designed to compare preventive percutaneous coronary intervention (PCI) plus optimal medical therapy (OMT) with OMT alone in patients with functionally nonsignificant high-risk vulnerable plaques. The PREVENT trial is a multinational, multicenter, prospective, open-label, active-treatment-controlled randomized trial. Eligible patients have at least 1 angiographically significant stenosis (diameter stenosis >50% by visual estimation) without functional significance (fractional flow reserve [FFR] >0.80). Target lesions are assessed by intracoronary imaging and must meet at least 2 imaging criteria for vulnerable plaque; (1) minimal lumen area <4.0 mm2; (2) plaque burden >70%; (3) maximal lipid core burden index in a 4 mm segment >315 by near infrared spectroscopy; and (4) thin cap fibroatheroma as determined by virtual histology or optical coherence tomography. Enrolled patients are randomly assigned in a 1:1 ratio to either preventive PCI with either bioabsorbable vascular scaffolds or metallic everolimus-eluting stents plus OMT or OMT alone. The primary endpoint is target-vessel failure, defined as the composite of death from cardiac causes, target-vessel myocardial infarction, ischemic-driven target-vessel revascularization, or hospitalization for unstable or progressive angina, at 2 years after randomization. Enrollment of a total of 1,608 patients has been completed. Follow-up of the last enrolled patient will be completed in September 2023 and primary results are expected to be available in early 2024. The PREVENT trial is the first large-scale, randomized trial to evaluate the effect of preventive PCI on non-flow-limiting vulnerable plaques containing multiple high-risk features that is appropriately powered for clinical outcomes. PREVENT will provide compelling evidence as to whether preventive PCI of vulnerable plaques plus OMT improves patient outcomes compared with OMT alone. URL: https://www. gov. Unique identifier: NCT02316886. The PREVENT trial is the first, large-scale randomized clinical trial to evaluate the effect of preventive PCI on non-flow-limiting vulnerable plaque with high-risk features. It will provide compelling evidence to determine whether PCI of focal vulnerable plaques on top of OMT improves patient outcomes.

The association between circulating lipoprotein subfractions and lipid content in coronary atheromatous plaques assessed by near-infrared spectroscopy

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Norwegian Health Association The Liaison Committee for education, research and innovation in Central Norway. Background Lipid content in coronary atheromatous plaques, measured by near-infrared spectroscopy (NIRS), can predict the risk of future coronary events. Biomarkers that reflect lipid content in coronary plaques may therefore improve coronary artery disease (CAD) risk assessment, and lipoprotein subfractions could potentially add value beyond traditional lipid measurements. Purpose We aimed to investigate the association between circulating lipoprotein subfractions and lipid content in coronary atheromatous plaques in statin-treated patients with stable CAD undergoing percutaneous coronary intervention. Methods 56 patients with stable CAD underwent three vessel imaging with NIRS when feasible. The coronary artery segment with the highest lipid content, defined as the maximum lipid core burden index within any 4mm length across the entire lesion (maxLCBI4mm), was selected as target segment. Lipoprotein subfractions were analyzed in fasting serum samples by nuclear magnetic resonance spectroscopy. Penalized linear regression analyses (lasso) were used to identify the best predictors of maxLCBI4mm. The uncertainty of the lasso estimates was assessed as the percentage of the resampled datasets by bootstrapping. Results Only modest evidence was found for an association with lipoprotein subfractions and maxLCBI4mm. The lipoprotein subfractions with strongest potential as predictors according to the percentage presence in resampled datasets were lipoprotein a (Lp(a)) (reg.coeff = 57.0; 78.1 % presence) and free cholesterol in the smallest high-density lipoprotein (HDL) subfractions (reg.coeff = 36.5; 74.3 % presence). When including established cardiovascular risk factors in the regression model, none of the lipoprotein subfractions was considered potential predictors of maxLCBI4mm. Conclusion In this study, Lp(a) and free cholesterol in the smallest HDL subfractions in serum showed the strongest potential as predictors for lipid content in coronary atheromatous plaques. Although the evidence is modest, our study suggests that measurements lipoprotein subfractions may provide additional information with respect to coronary plaque composition compared to traditional lipid measurements, but not in addition to established risk factors. Future studies are needed to verify our findings, and to investigate the clinical implication of lipoprotein subfractions as meaningful biomarkers for lipid-rich plaques and enhanced risk prediction in CAD.

Disparities among Black and White patients in plaque burden and composition and long-term impact

BackgroundBlack patients presenting to the catheterization laboratory have more risk factors and worse long-term outcomes. This sub-analysis of the Lipid Rich Plaque (LRP) study quantifies the plaque burden and composition of Black vs White patients and associated outcomes. MethodsPatients with a singular, self-reported race presenting for cardiac catheterization were enrolled if near-infrared spectroscopy/intravascular ultrasound (NIRS-IVUS) imaging of non-stented, non-culprit (NC) vessels was performed. Lipidic content was quantified at the 4-mm region with maximum Lipid Core Burden Index (maxLCBI4mm). NC major adverse cardiac events (NC-MACE) were defined as: cardiac death, cardiac arrest, non-fatal myocardial infarction, acute coronary syndrome, revascularization, and hospital readmission for angina with >20 % disease progression through 2 years. ResultsAmong 1346 patients with a singular, self-reported race, 182 were Black. Black vs White patients were more likely to be female, had higher rates of traditional risk factors, and were more likely to present acutely. Both patients and segments were more likely to have maxLCBI4mm > 400 (46.7 % vs 30.6 %, p < 0.001, respectively; 15.5 % vs 8.9 %, p < 0.001, respectively). Vessel size and plaque burden were larger for Black vs White patients. At 2 years, maxLCBI4mm > 400 and Black race were independently predictive of NC-MACE (hazard ratio [HR] maxLCBI4mm > 400: 2.37 [95 % confidence interval (CI) 1.50–3.76, p < 0.001], Black race: 2.8 [95 % CI 1.27–3.42, p = 0.004], pinteraction = 0.137). ConclusionsCompared to White patients, Black patients had more lipid-rich plaques with greater plaque burden. Both high lipidic burden and Black race were independently predictive of NC-MACE within 2 years. Clinical trial registrationhttps://clinicaltrials.gov/ct2/show/NCT02033694, NCT02033694

Multimodality imaging to identify lipid-rich coronary plaques and predict periprocedural myocardial injury: Association between near-infrared spectroscopy and coronary computed tomography angiography.

This study compares the efficacy of coronary computed tomography angiography (CCTA) and near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) in patients with significant coronary stenosis for predicting periprocedural myocardial injury during percutaneous coronary intervention (PCI). We prospectively enrolled 107 patients who underwent CCTA before PCI and performed NIRS-IVUS during PCI. Based on the maximal lipid core burden index for any 4-mm longitudinal segments (maxLCBI4mm) in the culprit lesion, we divided the patients into two groups: lipid-rich plaque (LRP) group (maxLCBI4mm ≥ 400; n = 48) and no-LRP group (maxLCBI4mm < 400; n = 59). Periprocedural myocardial injury was a postprocedural cardiac troponin T (cTnT) elevation of ≥5 times the upper limit of normal. The LRP group had a significantly higher cTnT (p = 0.026), lower CT density (p < 0.001), larger percentage atheroma volume (PAV) by NIRS-IVUS (p = 0.036), and larger remodeling index measured by both CCTA (p = 0.020) and NIRS-IVUS (p < 0.001). A significant negative linear correlation was found between maxLCBI4mm and CT density (rho = -0.552, p < 0.001). Multivariable logistic regression analysis identified maxLCBI4mm [odds ratio (OR): 1.006, p = 0.003] and PAV (OR: 1.125, p = 0.014) as independent predictors of periprocedural myocardial injury, while CT density was not an independent predictor (OR: 0.991, p = 0.22). CCTA and NIRS-IVUS correlated well to identify LRP in culprit lesions. However, NIRS-IVUS was more competent in predicting the risk of periprocedural myocardial injury.

Dual-layered stents reduce cerebral embolism compared with first-generation stents during carotid stenting of high lipid core plaque lesions

BackgroundPeriprocedural lipid core plaque (LCP) has been detected in carotid arteries assessed by catheter-based near-infrared spectroscopy (NIRS). High LCP is associated with cerebral embolism after carotid artery stenting (CAS) using...

Relation of GRACE Risk Score to Coronary Lipid Core Plaques in Patients with Acute Coronary Syndrome.

The GRACE risk score is established to predict thrombotic events in patients with acute coronary syndrome (ACS). Although thrombotic events including myocardial infarction after ACS are mainly attributable to vulnerable plaque formation, whether the GRACE score correlates with coronary lipid-rich plaque is unclear. A total of 54 patients with ACS undergoing primary percutaneous coronary intervention under near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) guidance were included in a prospective manner. Patients were divided into two groups according to the median of the GRACE risk score. Coronary lipid plaques in the target vessel were assessed by NIRS-IVUS with lipid core burden index (LCBI) and a maximum LCBI in 4 mm (maxLCBI4mm). The receiver operating characteristics (ROC) curve analysis was performed based on the major adverse cardiovascular events as an exploratory analysis. The GRACE risk score was significantly and positively correlated with LCBI (r = 0.31, p = 0.03) and maxLCBI4mm (r = 0.38, p = 0.006). LCBI (111.7 ± 85.7 vs. 169.0 ± 83.5, p = 0.02) and maxLCBI4mm (428.5 ± 227.1 vs. 600.6 ± 227.7, p = 0.009) in the target vessel were significantly higher in the high GRACE risk score group than their counterpart. In the ROC curve analysis, LCBI and maxLCBI4mm were predictive for clinical events. In conclusion, the higher GRACE risk score may serve as a discriminator of risk comprising more lipid-rich plaques as an underlying mechanism of an increased risk of thrombotic events after ACS. In patients with ACS, the higher GRACE risk score was significantly and modestly associated with greater coronary lipid plaques in the target vessel.

Coronary Artery Lesion Lipid Content and Plaque Burden in Diabetic and Nondiabetic Patients: PROSPECT II.

Patients with diabetes have increased rates of major adverse cardiac events (MACEs). We hypothesized that this is explained by diabetes-associated differences in coronary plaque morphology and lipid content. In PROSPECT II (Providing Regional Observations to Study Predictors of Events in the Coronary Tree), 898 patients with acute myocardial infarction with or without ST-segment elevation underwent 3-vessel quantitative coronary angiography and coregistered near-infrared spectroscopy and intravascular ultrasound imaging after successful percutaneous coronary intervention. Subsequent MACEs were adjudicated to either treated culprit lesions or untreated nonculprit lesions. This substudy stratified patients by diabetes status and assessed baseline culprit and nonculprit prevalence of high-risk plaque characteristics defined as maximum plaque burden ≥70% and maximum lipid core burden index ≥324.7. Separate covariate-adjusted multivariable models were performed to identify whether diabetes was associated with nonculprit lesion-related MACEs and high-risk plaque characteristics. Diabetes was present in 109 of 898 patients (12.1%). During a median 3.7-year follow-up, MACEs occurred more frequently in patients with versus without diabetes (20.1% versus 13.5% [odds ratio (OR), 1.94 (95% CI, 1.14-3.30)]), primarily attributable to increased risk of myocardial infarction related to culprit lesion restenosis (4.3% versus 1.1% [OR, 3.78 (95% CI, 1.12-12.77)]) and nonculprit lesion-related spontaneous myocardial infarction (9.3% versus 3.8% [OR, 2.74 (95% CI, 1.25-6.04)]). However, baseline prevalence of high-risk plaque characteristics was similar for patients with versus without diabetes concerning culprit (maximum plaque burden ≥70%: 90% versus 93%, P=0.34; maximum lipid core burden index ≥324.7: 66% versus 70%, P=0.49) and nonculprit lesions (maximum plaque burden ≥70%: 23% versus 22%, P=0.37; maximum lipid core burden index ≥324.7: 26% versus 24%, P=0.47). In multivariable models, diabetes was associated with MACEs in nonculprit lesions (adjusted OR, 2.47 [95% CI, 1.21-5.04]) but not with prevalence of high-risk plaque characteristics (adjusted OR, 1.21 [95% CI, 0.86-1.69]). Among patients with recent myocardial infarction, both treated and untreated lesions contributed to the diabetes-associated ≈2-fold increased MACE rate during the 3.7-year follow-up. Diabetes-related plaque characteristics that might underlie this increased risk were not identified by multimodality imaging. URL: https://www. gov; Unique identifier: NCT02171065.

Relationship Between Optical Coherence Tomography-Derived In-Stent Neoatherosclerosis and the Extent of Lipid-Rich Neointima by Near-Infrared Spectroscopy and Intravascular Ultrasound: A Multimodal Imaging Study.

Background In-stent restenosis, especially for neoatherosclerosis, is a major concern following percutaneous coronary intervention. This study aimed to elucidate the association of features of in-stent restenosis lesions revealed by optical coherence tomography (OCT)/optical frequency domain imaging (OFDI) and the extent of lipid-rich neointima (LRN) assessed by near-infrared spectroscopy (NIRS) and intravascular ultrasound, especially for neoatherosclerosis. Methods and Results We analyzed patients undergoing percutaneous coronary intervention for in-stent restenosis lesions using both OCT/OFDI and NIRS-intravascular ultrasound. OCT/OFDI-derived neoatherosclerosis was defined as lipid neointima. The existence of large LRN (defined as a long segment with 4-mm maximum lipid core burden index ≥400) was evaluated by NIRS. In 59 patients with 64 lesions, neoatherosclerosis and large LRN were observed in 17 (26.6%) and 21 lesions (32.8%), respectively. Naturally, large LRN showed higher 4-mm maximum lipid core burden index (median [interquartile range], 623 [518-805] versus 176 [0-524]; P<0.001). In OCT/OFDI findings, large LRN displayed lower minimal lumen area (0.9±0.4 versus 1.3±0.6 mm2; P=0.02) and greater max lipid arc (median [interquartile range], 272° [220°-360°] versus 193° [132°-247°]; P=0.004). In the receiver operating characteristic curve analysis, 4-mm maximum lipid core burden index was the best predictor for neoatherosclerosis, with a cutoff value of 405 (area under curve, 0.92 [95% CI, 0.83-1.00]). In multivariable logistic analysis, only low-density lipoprotein cholesterol (odds ratio, 1.52 [95% CI, 1.11-2.08]) was an independent predictor for large LRNs. Conclusions NIRS-derived large LRN was significantly associated with neoatherosclerosis by OCT/OFDI. The neointimal characterization by NIRS-intravascular ultrasound has potential as an alternative method of OCT/OFDI for in-stent restenosis lesions.

Abstract 13674: Optimal Hounsfield Threshold for Lipid-Rich Plaque by Artificial Intelligence-Enabled Quantitative CT Using Near-Infrared Spectroscopy

Introduction: By near-infrared spectroscopy (NIRS), plaques with 4-mm maximum lipid-core burden index (maxLCBI4 mm ) ≥ 400 are lipid-rich plaque. By CCTA, the optimal Hounsfield threshold (HU) for lipid-rich plaques defined by presence of low-density non-calcified plaque (LD-NCP) is still unclear. Hypothesis: Artificial intelligence-enabled quantitative CT (AI-QCT) will enable identification of HU for lipid-rich plaques when compared to NIRS reference standard. Methods: 128 atherosclerotic plaques from 47 patients were enrolled prospectively. MaxLCBI 4mm (cutoff was defined as 400) and LD-NCP derived from AI-QCT (Cleerly LABS, Denver CO) were compared. LD-NCP using 3 different thresholds (&lt;30, &lt;50, and &lt;70 HU) were analyzed by sensitivity, specificity, positive and negative predictive value, accuracy, and area Under the Curve (AUC). Results: Amongst 128 atherosclerotic plaques evaluated, 26 (20.3%) met NIRS criteria for lipid rich plaque (maxLCBI 4mm ≥400). The volume of LD-NCP was measure using three different thresholds, &lt;30, &lt;50, and &lt;70 HU as well as criteria of PR &gt; 1.1 and LD-NCP volume &gt;1.8 mm 3 (LD-NCP volume threshold identified from AUC). This yielded a sensitivity, specificity, positive and negative predictive value, accuracy, and AUC of 92%, 88%, 67%, 98%, 89%, and 0.944 at &lt;30HU, 96%, 79%, 53%,99% 82%, 0.921 at &lt;50HU, and 96% 72%, 46%, 99%, 77%, and 0.907 respectively at &lt;70HU (30 vs. 50 HU: p=0.008; 30 vs. 70HU: p=0.002 (Figure 1). Conclusions: A &lt;30 HU threshold for definition of LD-NCP on AI-QCT correlates optimally with NIRS proven lipid-rich plaques.