Abstract Background A recent randomized-controlled trial (Preventive percutaneous coronary intervention versus optimal medical therapy alone for the treatment of vulnerable atherosclerotic coronary plaques (PREVENT)) suggested prognostic benefit from preventive coronary intervention of vulnerable plaques (VP) as defined by intracoronary imaging. Purpose We aimed to test the feasibility of applying modified PREVENT-like vulnerability criteria to artificial intelligence (AI)-guided coronary computed tomography angiography (CCTA) analysis and assess outcomes of patients with VP according to revascularization vs. medical therapy. Methods This was a cohort of 2271 patients undergoing CCTA for suspected coronary artery disease from 2007 to 2016. CCTA scans were analyzed by AI-guided quantitative computed tomography (AI-QCT). The modified PREVENT-like vulnerability criteria were ≥70% percent atheroma volume (PAV) or lipid-rich plaque (LRP) (i.e. low-density non-calcified plaque (HU 30) ≥2.3 mm3 and positive remodeling) on a per-segment level. Patients were followed for a median of 7 years for major adverse cardiovascular events (MACE) (death, myocardial infarction (MI), or unstable angina (uAP); and acute coronary syndrome (ACS) (MI or uAP)). We assessed the prognostic value of VP and its interaction with early (6-month) revascularization using multivariable Cox regressions. Hazard ratios were adjusted (HRadj) for clinical confounders (age, sex, hypertension, diabetes, smoking, typical angina). Results Mean patient age was 62 years, 58% were females, and 212 underwent coronary revascularization. 170 coronary segments from 133/2271 (5.9%) patients fulfilled the modified PREVENT-like VP definition (Figure 1). Patients with VP had significantly higher rates of MACE (26.3% with VP vs. 10.3% without VP; HRadj 1.90, 95% CI 1.31-2.75, p=0.001) (Figure 2, A1), and ACS (12.0% with VP vs. 3.9% without VP; HRadj 2.22, 95% CI 1.27-3.87, p=0.005) (Figure 2, B1). There was significant interaction between VP and revascularization with respect to MACE (p-interaction=0.022) and ACS (p-interaction=0.005). Patients with VP had higher rates of MACE (HR 2.93, 95% CI 1.90-4.52, p0.001) and ACS (HR 4.29, 95% CI 2.25-8.16, p0.001) if receiving medical therapy alone, but not if undergoing revascularization (MACE: HR 1.11, 95% CI 0.57-2.17, p=0.746; ACS: HR 0.69, 95% CI 0.26-1.81, p=0.448) (Figure 2 A2-A3/B2-B3). Conclusion Vulnerable plaque based on PREVENT-like criteria on AI-guided CCTA was associated with increased risk of MACE and ACS if treated by medical therapy alone, but not in patients undergoing early revascularization. This may suggest that modified PREVENT-like VP criteria applied to CCTA could potentially help to identify patients benefitting from revascularization in terms of long-term outcome.Figure 1.Frequency of PREVENT-like VP Figure 2.Kaplan Meier Curves
Bär et al. (Sat,) studied this question.