Preventive Percutaneous Coronary Intervention for Vulnerable Plaques
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Key result
Preventive PCI for vulnerable plaques may reduce adverse events, driven by fewer repeat revascularizations.
Why the study?
Does preventive percutaneous coronary intervention reduce adverse cardiovascular events in patients with vulnerable atherosclerotic plaques?
Key Points
- To review the pathophysiological mechanisms, intracoronary imaging modalities, and clinical evidence surrounding preventive percutaneous coronary intervention for non-obstructive vulnerable atherosclerotic plaques.
- Synthesized findings from prospective clinical and natural history studies evaluating coronary lesions using intracoronary imaging modalities.
- Assessed diagnostic criteria derived from intravascular ultrasound (IVUS), optical coherence tomography (OCT), and near-infrared spectroscopy (NIRS).
- Evaluated clinical trial data regarding preventive plaque sealing and systemic pharmacotherapies.
- Morphologic plaque characteristics, including plaque burden ≥ 70%, minimal lumen area ≤ 4.0 mm², thin fibrous caps (< 65 µm), and lipid-rich cores, reliably identify non-flow-limiting lesions at increased risk of future coronary events.
- Preventive percutaneous coronary intervention in selected high-risk plaques reduces adverse cardiovascular events, although benefits are primarily driven by reductions in repeat revascularization rather than hard clinical endpoints.
- Lesion-level event rates for untreated individual non-culprit plaques remain low at only a few percent over several years, creating potential risks of overtreatment compared to intensive systemic lipid-lowering therapy.
Structured PICO
Does preventive percutaneous coronary intervention reduce adverse cardiovascular events in patients with vulnerable atherosclerotic plaques?
I
Intervention
Preventive percutaneous coronary intervention (PCI) / plaque sealing
Preventive PCI for vulnerable plaques is an emerging strategy that may reduce repeat revascularization, but requires further evidence regarding hard clinical endpoints, optimal imaging criteria, and cost-effectiveness before widespread adoption.
Limitations
- The overall event rate from individual non-culprit lesions remains relatively low, which may lead to overtreatment and unnecessary procedural risks.
- Optimal imaging criteria for identifying plaques that warrant intervention remain uncertain.
- The long-term safety and cost-effectiveness of preventive PCI have not yet been fully established.
- Overall event rate from individual non-culprit lesions remains relatively low, which may lead to overtreatment and unnecessary procedural risks
- Optimal imaging criteria for identifying plaques that warrant intervention remain uncertain
- Long-term safety and cost-effectiveness of preventive PCI have not yet been fully established
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
DJDavid J. CohenInterventional cardiologist, Cardiovascular Research Foundation
“However, many of the events prevented were subsequent PCIs, so future studies focused on death and myocardial infarction outcomes are needed.”
“The first and perhaps most important issue is the small number of events in the 2-year analysis. In a trial of more than 1600 patients, there were only 24 fewer (mostly nonfatal) primary outcome events in the PCI arm. Longer follow-up exposes the fragility of that result. As the number of events accrued, the difference in events lessened. At 4 and 7 years, the lower rates of the primary outcome in the PCI arm no longer met statistical significance. If the treatment was as good as an 89% lower hazard rate would suggest, you'd expect more events to strengthen, not weaken, confidence in the treatment effect.”
RARasha Al-LameeInterventional cardiologist, Imperial College London
“The criteria for vulnerable plaque in this population was, for the vast majority, a lesion that was tight on IVUS or a significant plaque burden. It was actually a very small proportion of patients that had thin cap atheroma, that had the various vulnerable plaque characteristics we look for. And importantly, over 70% of patients had gray-scale IVUS, which is not very good for looking at these vulnerable features.”
Implication
Does not support routine preventive PCI; leaves open need for RCTs on hard endpoints in imaging-identified vulnerable plaques.
Abstract
Acute coronary syndrome is frequently caused by the disruption of vulnerable atherosclerotic plaques, many of which are angiographically non-obstructive before the event. Advances in intracoronary imaging, including intravascular ultrasound, optical coherence tomography, and near-infrared spectroscopy, have enabled visualization of high-risk plaque features such as large plaque burden, lipid-rich cores, thin fibrous caps, and inflammatory activity. Prospective studies have demonstrated that these plaque characteristics are associated with an increased risk of future cardiovascular events. These observations have led to the concept of preventive percutaneous coronary intervention (PCI), also referred to as “plaque sealing”.
Discussion
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Cite This Study
Kyohei Yamaji (2026) conducted a review in Vulnerable atherosclerotic plaques. Preventive percutaneous coronary intervention (PCI) vs. Optimal medical therapy was evaluated. Preventive PCI for vulnerable plaques may reduce adverse cardiovascular events, primarily driven by fewer repeat revascularizations, though its impact on hard clinical endpoints remains unclear.
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