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Observational Study
. 2025 Jan 31;26(2):197-206.
doi: 10.1093/ehjci/jeae289.

High-risk plaques in non-culprit lesions and clinical outcome after NSTEMI vs. STEMI

Rick H J A Volleberg  1 , Jan-Quinten Mol  1 , Anouar Belkacemi  2 , Renicus S Hermanides  3 , Martijn Meuwissen  4 , Alexey V Protopopov  5   6 , Peep Laanmets  7 , Oleg V Krestyaninov  8 , Casper F Laclé  9 , Rohit M Oemrawsingh  4   10 , Jan-Peter van Kuijk  11 , Karin Arkenbout  12 , Dirk J van der Heijden  3   13 , Saman Rasoul  14   15 , Erik Lipsic  16 , Laura Rodwell  17 , Cyril Camaro  1 , Peter Damman  1 , Tomasz Roleder  18 , Elvin Kedhi  19 , Maarten A H van Leeuwen  3 , Robert-Jan M van Geuns  1 , Niels van Royen  1
Affiliations
Observational Study

High-risk plaques in non-culprit lesions and clinical outcome after NSTEMI vs. STEMI

Rick H J A Volleberg et al. Eur Heart J Cardiovasc Imaging. .

Abstract

Aims: Complete non-culprit (NC) revascularisation may help reduce recurrent events after non-ST-segment elevation myocardial infarction (NSTEMI), especially if NC lesions would harbour high-risk plaque (HRP) features similar to ST-segment elevation myocardial infarction (STEMI). This study aimed to assess differences in fractional flow reserve (FFR)-negative NC plaque morphology in patients presenting with NSTEMI vs. STEMI and assess the association of HRP morphology and clinical outcome.

Methods and results: In the prospective PECTUS-obs study, 438 patients presenting with myocardial infarction (MI) underwent optical coherence tomography (OCT) of all FFR-negative intermediate NC lesions. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE, composite of all-cause mortality, non-fatal MI or unplanned revascularisation) at 2-year follow-up. Four hundred and twenty patients had at least one analysable OCT, including 203 (48.3%) with NSTEMI and 217 (51.7%) with STEMI. The prevalence of HRPs, including thin-cap fibroatheromas, plaque rupture, and thrombus, was comparable between groups. MACE occurred in 29 (14.3%) NSTEMI patients and 16 (7.4%) STEMI patients (Puni-variable = 0.025 and Pmulti-variable = 0.270). Incidence of MACE was numerically higher among patients with HRP, irrespective of the clinical presentation at index (Pinteraction = 0.684). Among HRP criteria, plaque rupture was associated with MACE in both NSTEMI (P < 0.001) and STEMI (P = 0.020).

Conclusion: Presence of NC HRP is comparable between NSTEMI and STEMI and leads to numerically higher event rates in both. These results call for additional research on complete revascularisation in NSTEMI and treatment of HRP.

Clinical trial registration: NCT03857971.

Keywords: NSTEMI; STEMI; TCFA; fractional flow reserve; high-risk plaque; non-culprit; plaque rupture.

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Conflict of interest statement

Conflict of interest: R.H.J.A.V. reported receiving grant funding from Abbott Vascular and Health~Holland during the conduct of the study. J.-Q.M. reported receiving grant funding from Abbott Vascular and Health~Holland during the conduct of the study. A.B. reported receiving speaker’s fees from Daiichi Sankyo Inc, travel fees from Novo Nordisk and Daiichi Sankyo, and is shareholder of Pfizer, outside the submitted work. R.S.H. reported receiving speaker fees from Amgen Inc, Angiocare, Edwards Lifesciences and Novartis AG outside the submitted work. R.M.O. reported receiving speaker fees from Abbott Vascular outside the submitted work. E.L. reported receiving grant funding from Abbott Laboratories outside the submitted work. C.C. reported receiving honorarium for organizing regional meetings from AstraZeneca outside the submitted work. P.D. reported receiving grant funding from Abbott Laboratories, AstraZeneca and Philips, ans consulting fees from Abbott Laboratories outside the submitted work. E.K. reported receiving grant funding from Abbott Laboratories and Medtronic, and proctorship honoraria from Abbott laboratories outside the submitted work. M.A.H.v.L. reported receiving grant funding from AstraZeneca, Top Sector Life Sciences & Health, Terumo Corporation, TOP Medical BV, and Abbott Laboratories and speakers’ fees and consulting from Terumo Corporation, Daiichi Sankyo Inc, and Abbott Laboratories outside the submitted work. R.-J.M.v.G. reported receiving grant funding from InfraRedx, and speaker fees from Amgen and Sanofi outside the submitted work. N.v.R. reported receiving grant funding and personal fees from Abbott Vascular and Health~Holland during the conduct of the study and grants from Philips, Biotronik, and Medtronic Inc, and speaker fees from Bayer AG, MicroPort, and RainMed Medical outside the submitted work.

Figures

Graphical Abstract
Graphical Abstract
The presence of at least one optical coherence tomography-identified high-risk plaque (pre-defined in the presence of at least two characteristics: (i) lipid arc ≥90° (A-C), (ii) minimum fibrous cap thickness <65 µm (A, C), and/or (iii) presence of either plaque rupture (B) or thrombus (C)) in afractional flow reserve-negative intermediate non-culprit lesion leads to numerically higher incidences of major adverse cardiovascular events (composite endpoint of all-cause mortality, non-fatal myocardial infarction, or unplanned revascularisation) on a patient-level at 2-year follow-up after NSTEMI and STEMI (right panels). Among high-risk plaque features, plaque rupture was significantly associated with adverse outcome in both NSTEMI and STEMI. CI, confidence interval; HR, hazard ratio; HRP, high-risk plaque; MACE, major adverse cardiovascular events; NSTEMI, non-ST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction; TCFA, thin-cap fibroatheroma
Figure 1
Figure 1
Study flowchart. Flowchart of subjects included in the study. FFR, fractional flow reserve; HRP, high-risk plaque; NSTEMI, non-ST-segment elevation myocardial infarction; NC, non-culprit; OCT, optical coherence tomography; STEMI, ST-segment elevation myocardial infarction.
Figure 2
Figure 2
Two-year MACE. Kaplan–Meier curve for the primary clinical outcome of MACE (composite endpoint of all-cause mortality, non-fatal MI, or unplanned revascularisation) at 2 year follow. NSTEMI, non-ST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction.
Figure 3
Figure 3
Two-year MACE and presence of HRP. Kaplan–Meier curve for the primary clinical outcome of MACE (composite endpoint of all-cause mortality, non-fatal MI, or unplanned revascularisation) at 2 year follow according to the presence of a HRP in NSTEMI and STEMI. CI, confidence interval; HRP, high-risk plaque; HR, hazard ratio; NSTEMI, non-ST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction.
See this image and copyright information in PMC

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