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Observational Study
. 2025 Oct 6;21(19):e1147-e1158.
doi: 10.4244/EIJ-D-25-00307.

Impact of clinical risk characteristics on the prognostic value of high-risk plaques

Rick H J A Volleberg  1 , Andi Rroku  2   3 , Jan-Quinten Mol  1 , Renicus S Hermanides  4 , Maarten van Leeuwen  4 , Balázs Berta  4   5 , Martijn Meuwissen  6 , Fernando Alfonso  7 , Wojciech Wojakowski  8 , Anouar Belkacemi  9 , Giuseppe De Luca  10   11 , Laura Rodwell  12 , Tomasz Roleder  13 , Elvin Kedhi  14 , Niels van Royen  1
Affiliations
Observational Study

Impact of clinical risk characteristics on the prognostic value of high-risk plaques

Rick H J A Volleberg et al. EuroIntervention. .

Abstract

Background: High-risk coronary plaques (HRPs) are associated with adverse cardiovascular outcomes. However, the clinical practicality of HRP identification is challenged by their modest prevalence and low positive predictive value.

Aims: We aimed to evaluate the association between clinical risk factors and HRPs, as well as the clinical impact of HRPs across different clinical risk profiles.

Methods: This is a pooled analysis of individual patient data from the prospective observational COMBINE (OCT-FFR) and PECTUS-obs studies. A modified version of the Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS-2P) was used for risk stratification. The composite endpoint of major adverse cardiovascular events (MACE) was evaluated on a patient level, and target lesion failure (TLF), also a composite endpoint, was evaluated on a lesion level.

Results: Among 810 patients, 311, 265, and 234 were at low (TRS-2P 0-1), intermediate (TRS-2P 2), and high risk (TRS-2P ≥3), respectively. The modified TRS-2P had no discriminative value for the identification of patients with an HRP (area under the receiver operating characteristic curve 0.51, 95% confidence interval [CI]: 0.47-0.56). A consistent trend towards worse clinical outcome in the presence of an HRP was observed across different clinical risk profiles (pinteraction=0.539 for MACE and 0.337 for TLF). For TLF, the highest event rate per 100 lesion-years was observed in high-risk patients with HRPs (6.28, 95% CI: 3.52-10.36; 13.6% absolute risk at 2 years).

Conclusions: HRPs are associated with a negative clinical outcome, without apparent differences between clinical risk profiles. This highlights the independent value of optical coherence tomography for prognostication beyond clinical risk factors. The high event rates in high-risk patients with HRPs necessitate the search for additional therapeutic strategies to mitigate this risk.

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Conflict of interest statement

R.S. Hermanides reports speaker honoraria from Amgen, Novartis, Edwards Lifesciences, and Angiocare. M. van Leeuwen reports research grants from Abbott, TOP Medical B.V., Terumo, and AstraZeneca; consulting fees from Terumo, Daiichi Sankyo, and Abbott; and speaker honoraria from CVOI. A. Belkacemi reports speaker honoraria from Daiichi Sankyo; travel fees from Novo Nordisk and Daiichi Sankyo; stock from Pfizer. E. Kedhi reports institutional research grants from Abbott and Medtronic. N. van Royen reports institutional research grants from Abbott, Health~Holland, Koninklijke Philips NV, Biotronik, and Medtronic; and speaker honoraria from MicroPort, Bayer AG, and RainMed Medical. The other authors have no conflicts of interest to declare.Impact on daily practiceThe presence of high-risk plaques cannot be predicted using clinical risk factors, and intracoronary optical coherence tomography has independent value for prognostication beyond traditional clinical risk factors. Nevertheless, patients at the highest risk for recurrent events can be identified by combining clinical risk scores and high-risk plaque imaging.

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