Landmark Trial Illuminates Coronary Plaques That Trigger Cardiac Events

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New study leads to important new insights into high risk coronary lesions for heart attacks. This may lead to routine studies beyond coronary angiography and may provide the basis for new treatment strategies, both medical and invasive.

Dr. Sheldon Goldberg and Dr. Dan McCormick discuss the PROSPECT trial that illuminates coronary plaques that trigger cardiac events. New study leads to important new insights into high risk coronary lesions for heart attacks. This may lead to routine studies beyond coronary angiography and may provide the basis for new treatment strategies, both medical and invasive.

Findings of the "Providing Regional Observations to Study Predictors of Events in the Coronary Tree" (PROSPECT) trial appeared in the Jan. 20 issue of the New England Journal of Medicine.

Results of a clinical trial provide insight to the types of vulnerable plaques that are most likely to cause sudden, unexpected adverse cardiac events, as well as ways to use imaging techniques to predict such events before they occur.

"As a result of the PROSPECT trial, we are closer to being able to predict - and therefore prevent - sudden, unexpected adverse cardiac events," said principal investigator Gregg W. Stone, MD, Professor of Medicine, Columbia University College of Physicians.

The trial studied 700 patients at multiple centers with acute coronary syndromes. Among the findings, most untreated plaques that cause unexpected heart attacks are not mild lesions, as previously thought, but have a large plaque burden, a small lumen area or both. Such characteristics were invisible to a standard imaging technique, the coronary angiogram, but easily identifiable by the newer grayscale intravascular ultrasound (IVUS).

In acute coronary syndrome patients treated with stents, major adverse cardiovascular events that occurred during a follow-up of 3 years were likely to result from a nonculprit lesion-that is, in a separate lesion not previously treated.

In addition, characterization of the underlying plaque composition using radiofrequency IVUS, also known as VH-IVUS, significantly improved the ability to predict future adverse events when compared with more standard imaging techniques. With VH-IVUS, mild lesions on coronary angiography can be evaluated for necrotic plaque centers and thin caps that are at especially high risk of causing future cardiovascular events.

Acute Coronary Syndromes ACS) commonly occur from mild coronary lesions with thin caps, large plaque burdens, and small lumens. These lesions carry a high risk of causing MI and death. Therefore, identifying the risk of each lesion is critical to reducing the occurrence of future MI and death. Current standard coronary angiography techniques may be insufficient to identify the highest risk patients and suggests that future investigation should focus on identifying asymptomatic or minimally symptomatic pts with large plaque burden, small coronary lumens, and thin-capped plaques through noninvasive screening (e.g. multi-slice CT scans), for intensive medical therapy and possibly invasive imaging and Rx.

Future research will use more sophisticated imaging modalities such as optical frequency domain imaging which has far greater resolving power to measure cap thickness-a key variable in assessing plaques which are vulnerable to future rupture. In addition, local plaque stabilization with devices such as coronary shields or bioresorbable stents will be tested in an effort to prevent acute myocardial infarction and sudden cardiac death.

These studies are of particular importance since half of patients who have acute myocardial infarction die before they reach the hospital. If vulnerable plaques could be identified and treated before they rupture, we may have a strategy to save hundreds of thousands of lives.

Dan McCormick, D.O.             
Sheldon Goldberg, M.D.

Source: Judge MED
Judge MED offers focused Interventional Cardiovascular virtual training covering areas such as acute MI, complex coronary disease, carotid, peripheral vascular & structural heart disease. Developed and taught by world renowned cardiovascular physicians, Judge MED’s goal is to teach and enhance procedural knowledge of therapies in interventional medicine.

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Jeffrey Ball