Fractional Flow Reserve–Negative High-Risk Plaques in MI (2024)

• ¹Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands

• ²Department of Cardiology, AZ West Hospital, Veurne, Belgium

• ³Department of Cardiology, Isala Hospital, Zwolle, the Netherlands

• ⁴Department of Cardiology, Amphia Hospital, Breda, the Netherlands

• ⁵Cardiovascular Center of Regional State Hospital, Krasnoyarsk, Russia

• ⁶Cardiology Center, North Estonia Medical Center, Tallinn, Estonia

• ⁷Meshalkin National Medical Research Center, Novosibirsk, Russia

• ⁸Department of Cardiology, Dr. Horacio E. Oduber Hospital, Oranjestad, Aruba

• ⁹Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, the Netherlands

• ¹⁰Department of Cardiology, Sint Antonius Hospital, Nieuwegein, the Netherlands

• ¹¹Department of Cardiology, Tergooi Hospital, Blaricum, the Netherlands

• ¹²Department of Cardiology, Haaglanden Medical Center, The Hague, the Netherlands

• ¹³Department of Cardiology, Zuyderland Medical Center, Heerlen, the Netherlands

• ¹⁴Department of Cardiology, Maastricht University Medical Center+, Maastricht, the Netherlands

• ¹⁵Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands

• ¹⁶Department of Epidemiology, Biostatistics and Health Technology Assessment, Radboud University Medical Center, Nijmegen, the Netherlands

• ¹⁷Department of Cardiology, Regional Specialist Hospital, Wrocław, Poland

• ¹⁸Department of Cardiology, Erasmus Hospital, Université libre de Bruxelles, Brussels, Belgium

Key Points

Question What is the association of optical coherence tomography–identified high-risk fractional flow reserve–negative nonculprit plaques with major adverse cardiovascular events (MACE) in patients presenting with myocardial infarction (MI)?

Findings In this cohort study of 420 patients with MI, MACE (defined as all-cause mortality, nonfatal MI, and unplanned revascularization) occurred in 22 of 143 patients with (15%) and 23 of 277 without (8%) a high-risk plaque after 2 years. After adjustment for clinical variables, presence of a high-risk plaque was associated with a 2-fold increased risk of MACE, driven primarily by higher rates of revascularization.

Meaning These findings suggest that among patients with MI, the presence of a fractional flow reserve–negative high-risk nonculprit plaque is associated with worse clinical outcome.

Importance Even after fractional flow reserve (FFR)–guided complete revascularization, patients with myocardial infarction (MI) have high rates of recurrent major adverse cardiovascular events (MACE). These recurrences may be caused by FFR-negative high-risk nonculprit lesions.

Objective To assess the association between optical coherence tomography (OCT)-identified high-risk plaques of FFR-negative nonculprit lesions and occurrence of MACE in patients with MI.

Design, Setting, and Participants PECTUS-obs (Identification of Risk Factors for Acute Coronary Events by OCT After STEMI [ST-segment elevation MI] and NSTEMI [non-STEMI] in Patients With Residual Non–flow Limiting Lesions) is an international, multicenter, prospective, observational cohort study. In patients presenting with MI, OCT was performed on all FFR-negative (FFR > 0.80) nonculprit lesions. A high-risk plaque was defined containing at least 2 of the following prespecified criteria: (1) a lipid arc at least 90°, (2) a fibrous cap thickness less than 65 μm, and (3) either plaque rupture or thrombus presence. Patients were enrolled from December 14, 2018, to September 15, 2020. Data were analyzed from December 2, 2022, to June 28, 2023.

Main Outcome and Measure The primary end point of MACE, a composite of all-cause mortality, nonfatal MI, or unplanned revascularization, at 2-year follow-up was compared in patients with and without a high-risk plaque.

Results A total of 438 patients were enrolled, and OCT findings were analyzable in 420. Among included patients, mean (SD) age was 63 (10) years, 340 (81.0) were men, and STEMI and non-STEMI were equally represented (217 [51.7%] and 203 [48.3%]). A mean (SD) of 1.17 (0.42) nonculprit lesions per patient was imaged. Analysis of OCT images revealed at least 1 high-risk plaque in 143 patients (34.0%). The primary end point occurred in 22 patients (15.4%) with a high-risk plaque and 23 of 277 patients (8.3%) without a high-risk plaque (hazard ratio, 1.93 [95% CI, 1.08-3.47]; P = .02), primarily driven by more unplanned revascularizations in patients with a high-risk plaque (14 of 143 [9.8%] vs 12 of 277 [4.3%]; P = .02).

Conclusions and Relevance Among patients with MI and FFR-negative nonculprit lesions, the presence of a high-risk plaque is associated with a worse clinical outcome, which is mainly driven by a higher number of unplanned revascularizations. In a population with a high recurrent event rate despite physiology-guided complete revascularization, these results call for research on additional pharmacological or focal treatment strategies in patients harboring high-risk plaques.

Cardiology Percutaneous Coronary Intervention Acute Coronary Syndromes Ischemic Heart Disease

Citation

Mol J, Volleberg RHJA, Belkacemi A, et al. Fractional Flow Reserve–Negative High-Risk Plaques and Clinical Outcomes After Myocardial Infarction. JAMA Cardiol. 2023;8(11):1013–1021. doi:10.1001/jamacardio.2023.2910

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