Lipid-Rich Plaque May Identify Who Benefits From Preventive PCI

Among patients with non–flow-limiting coronary lesions, preventive percutaneous coronary intervention (PCI) was associated with a lower risk of cardiac events in those with lipid-rich plaque (LRP) on near-infrared spectroscopy but not in those without, according to a post hoc analysis of the PREVENT trial published in Circulation.

The investigators noted that identifying which high-risk, non–flow-limiting plaques (fractional flow reserve >0.80) benefit most from preventive PCI compared with optimal medical therapy (OMT) alone remains challenging. They assessed whether the lipid core burden index derived from near-infrared spectroscopy could help.

PREVENT was an investigator-initiated, multicenter, open-label, randomized controlled trial that enrolled 1606 patients. This analysis included 598 patients (mean age, 64.1 years; 27.9% women) who also underwent near-infrared spectroscopy, with 632 lesions showing a plaque burden >70% and a minimal lumen area <4 mm² on intravascular ultrasound. LRP was prespecified as a maximum lipid core burden index >315 over a 4-mm segment. The primary outcome was a composite of cardiac death, target-vessel myocardial infarction, ischemia-driven target-vessel revascularization, or hospitalization for unstable or progressive angina.

LRP was present in 223 patients (37.3%). Over a median follow-up of 5.6 years, primary outcome events occurred more often in patients with LRP than in those without (12.5% vs 4.7%; unadjusted hazard ratio [HR], 2.08; 95% CI, 1.03-4.19). Within the LRP group, preventive PCI was associated with a lower risk of the primary outcome than OMT alone (7.3% vs 17.6%; adjusted HR, 0.23; 95% CI, 0.13-0.41). No benefit of preventive PCI was observed in the non-LRP group (5.5% vs 4.2%; adjusted HR, 1.00; 95% CI, 0.54-1.86), and the interaction between treatment strategy and LRP status was significant (P for interaction <0.001).

The authors noted that preventive PCI showed no significant association in patients without LRP despite their large plaque burden and small minimal lumen area. They concluded that the findings "suggest the importance of plaque composition, beyond morphological severity alone, in guiding preventive PCI."

Source: Wee SB, Ahn JM, Kang DY, et al. Lipid burden and efficacy of preventive PCI of vulnerable atherosclerotic coronary plaques: post hoc analysis from the PREVENT trial. Circulation. Published online October 6, 2026. doi:10.1161/CIRCULATIONAHA.126.080384