Centro per la Lotta Contro L'Infarto-CLI Foundation, Rome, Italy; UniCamillus - Saint Camillus International University of Health Sciences, Rome, Italy.
Centre for Inherited Cardiovascular Diseases, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy.
JACC Cardiovasc Interv. 2021 Feb 22;14(4):468-473. doi: 10.1016/j.jcin.2020.12.033.
In this viewpoint paper, the authors are tackling criticism to the limits of invasive imaging modalities for identification and treatment of vulnerable plaques. They believe in the clinical usefulness of invasive imaging modalities for identification of vulnerable plaques, and are suggesting an explanation for the suboptimal results of past studies, that failed to demonstrate a correlation between interventional treatment of vulnerable plaques, and reduction of hard clinical endpoints. Vulnerability studies have been based, so far, on the detection and measurement of plaques lipid content, because of its ease. However, the search for lipid "lakes" as a single common causal feature of acute coronary syndromes does not seem sufficient to identify patients at risk of adverse events. New imaging studies provided the rationale for improving clinical outcomes, adopting a more comprehensive assessment of target plaque morphology. There is little rationale in pursuing a functional assessment of coronary lesions to predict myocardial infarction. Recent studies are further confirming this hypothesis, suggesting that the clinical benefit of the fractional flow reserve-guided strategy is simply due to a significant reduction in the rate of repeated revascularizations, with no significant differences in the incidence of hard endpoints. There is a need to develop new randomized studies, requiring a feasible number of patients, to test the superiority of an approach based on vulnerable plaque sealing and treatment.
在这篇观点文章中，作者针对侵袭性影像学在识别和治疗易损斑块方面的局限性提出了批评。他们相信侵袭性影像学在识别易损斑块方面具有临床应用价值，并对过去未能证明易损斑块介入治疗与硬终点减少之间存在相关性的研究结果提出了一种解释。脆弱性研究迄今为止一直基于检测和测量斑块脂质含量，因为这很容易做到。然而，寻找脂质“湖”作为急性冠脉综合征的单一共同因果特征，似乎不足以识别有不良事件风险的患者。新的影像学研究为改善临床结果提供了依据，采用更全面的目标斑块形态评估。为预测心肌梗死而对冠状动脉病变进行功能评估的理由并不充分。最近的研究进一步证实了这一假设，表明血流储备分数指导策略的临床获益仅仅是由于重复血运重建的发生率显著降低，而硬终点的发生率没有显著差异。有必要开展新的随机研究，需要有一定数量的患者来测试基于易损斑块密封和治疗的方法的优越性。
