Prognostic implications of multiple simultaneously occurring high-risk plaque structures within the same ACS-causing culprit lesion. Insights from the OPTICO-ACS study

G. Nelles (Frankfurt am Main)¹, Y. Abdelwahed (Berlin)², C. Seppelt (Frankfurt am Main)¹, D. Meteva (Berlin)², B. Stähli (Zürich)³, L. M. Seegers (Frankfurt am Main)¹, C. Skurk (Berlin)², A. Haghikia (Bochum)⁴, H. Dreger (Berlin)⁵, F. Knebel (Berlin)⁶, T. D. Trippel (Berlin)⁷, M. Krisper (Berlin)⁸, M. Joner (München)⁹, U. Landmesser (Berlin)¹⁰, D. Leistner (Frankfurt am Main)^1
1Universitätsklinikum Frankfurt Med. Klinik III - Kardiologie, Angiologie Frankfurt am Main, Deutschland; ²Charité - Universitätsmedizin Berlin CC 11: Med. Klinik für Kardiologie Berlin, Deutschland; ³UniversitätsSpital Zürich Universitäres Herzzentrum Zürich, Schweiz; ⁴Klinikum der Ruhr-Universität Bochum Medizinische Klinik II, Kardiologie Bochum, Deutschland; ⁵Deutsches Herzzentrum der Charite (DHZC) Klinik für Kardiologie, Angiologie und Intensivmedizin | CBF Berlin, Deutschland; ⁶Sana Klinikum Lichtenberg Klinik für Innere Medizin II, Schwerpunkt Kardiologie Berlin, Deutschland; ⁷Charité - Universitätsmedizin Berlin CC11: Med. Klinik m.S. Kardiologie Berlin, Deutschland; ⁸Praxis Rankestrasse Kardiologisch-Angiologisch-Internistische Praxisgemeinschaft Berlin, Deutschland; ⁹Deutsches Herzzentrum München Klinik für Herz- und Kreislauferkrankungen München, Deutschland; ¹⁰Deutsches Herzzentrum der Charite (DHZC) Klinik für Kardiologie, Angiologie und Intensivmedizin Berlin, Deutschland

Background: Optical coherence tomography (OCT) allows intracoronary assessment of high-risk plaque features within culprit lesions (CL) of patients presenting with acute coronary syndrome (ACS). The co-existence of multiple high-risk coronary plaque structures showed a strong association with adverse cardiac events in patients with stable coronary artery disease (CAD). However, this effect has not been investigated in ACS patients yet. The present study aimed to comprehensively analyze the relationship between individual high-risk plaque features and cardiovascular outcomes at two years follow-up and to explore the predictive value of the simultaneous presence of multiple high-risk features within the same CL.

Methods: Within the prospective, multicentric OPTICO-ACS study, the CL of 346 ACS-patients undergoing pre-intervention OCT-imaging were screened for the presence of conventional high-risk plaque features. The primary endpoint was the incidence of major adverse cardiac events plus (MACE+) consisting of cardiac death, myocardial infarction, target vessel revascularization and re-hospitalization due to unstable or progressive angina at two years. Continuous variables were dichotomized according to the study-specific cut-off values, derived via receiver operating analyses and Youden’s index.  The relationship between each individual and multiple co-occurring high-risk features were compared between patients with – and without clinical events using cox regression analysis.

Results: RFC-ACS [80% vs 51.2%; HR=1.816 (1.050-3.142); p=0.033], cholesterol crystals [71.3% vs 53.5%; HR=1.936 (1.193-3.142); p=0.008] and a high maximum lipid arc beyond the cut-off of 250° [78.8% vs. 48.2%; HR= 1.947 (1.140-3.328); p=0.015)] each occurred more frequently in patients with clinical events as compared to patients without clinical events. The co-existence of all three high-risk plaque features within the same CL showed the strongest association with the primary endpoint (HR=2.282 (1.462-3.562; p<0.001). Furthermore, the co-existence of all three structures within the same CL had the highest specificity (65.50%) and positive predictive value (34.56%) for the primary endpoint, when compared to each individual feature occurring alone.

Conclusions: More than one third of patients with the co-existence of three high-risk plaque features within the same CL suffered from a clinical event within two years of follow-up. This finding may support risk stratification after ACS and may justify enhanced secondary preventive measures.