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OCT Identified Nonobstructive STEMI Lesions that Do Not Need Stenting
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A recent multicenter study proposes that identification of nonobstructive, plaque erosion lesions with optical coherence tomography may allow management of a subset of ACS patients without the need of stenting.
“ACS commonly result from the rupture of fibrous cap [RFC] of the lipid-rich large atherosclerotic plaques,” Jagat Narula, MD, PhD, study investigator with Mount Sinai Hospital, New York, told Cardiology Today’s Intervention. “In approximately one-fourth of patients, the plaque may not be lipid-rich, occlusive or always associated with standard risk factors and may often affect women and young; such events with intact fibrous cap [IFC] are presumed to result from the plaque erosion. It is now possible to clinically classify the plaques into those with RFC vs. an IFC by employing OCT.”
Jagat Narula
In the study, which was published in the Journal of the American College of Cardiology: Cardiovascular Imaging, Narula and colleagues performed OCT imaging after thrombus aspiration to find IFC of the culprit lesion in 31 patients with STEMI that were subcritically occlusive; 40% of patients were treated with dual antiplatelet therapy without PCI and the remaining 60% underwent angioplasty and stenting. The decision of how to treat was left to the interventional cardiologist.
At follow-up (median, 753 days), all patients were asymptomatic, regardless of treatment.
“A reliable identification of IFC may have practical implications for management, allowing selection of patients who can be treated with DAPT without intra-coronary stenting,” Narula said.
Eugene Braunwald
In an accompanying editorial, Eugene Braunwald, MD, with Brigham and Women’s Hospital and Harvard Medical School, wrote that although plaque erosion is not the most common cause of coronary thrombosis and STEMI, it certainly is not an infrequent cause.
“OCT is a relatively new imaging modality and is now being introduced into a variety of clinical situations,” Braunwald wrote. “Its application … in 12 patients with STEMI secondary to plaque erosion who were treated successfully without PCI should lead to further investigation of this ingenious therapeutic approach.”
Prati F. J Am Coll Cardiol Img. 2013;6:283-287.
Braunwald E. J Am Coll Cardiol Img. 2013;6:288-289.
Disclosure: Narula reports a relationship with St. Jude Medical. Braunwald reports no relevant financial disclosures.