Thrane Pernille G, Maeng Michael, Maehara Akiko, Bøtker Hans Erik, Mintz Gary S, Kjøller-Hansen Lars, Engstrøm Thomas, Matsumura Mitsuaki, Kotinkaduwa Lak N, Fröbert Ole, Persson Jonas, Wiseth Rune, Larsen Alf I, Jensen Lisette O, Nordrehaug Jan E, Bleie Øyvind, Held Claes, James Stefan K, Ali Ziad A, Erlinge David, Stone Gregg W
Department of Cardiology, Aarhus University Hospital, Denmark (P.G.T., M. Maeng, H.E.B.).
Department of Clinical Medicine, Aarhus University, Denmark (P.G.T., M. Maeng, H.E.B., O.F.).
Circulation. 2025 Jun 24;151(25):1767-1779. doi: 10.1161/CIRCULATIONAHA.124.071980. Epub 2025 Jun 23.
Clinical guidelines recommend different revascularization strategies for nonculprit lesions in patients with ST-segment-elevation myocardial infarction (STEMI) versus non-STEMI (NSTEMI). Whether the prevalence of untreated high-risk vulnerable plaques differs in STEMI and NSTEMI and affects their outcomes is unknown.
In PROSPECT II (Providing Regional Observations to Study Predictors of Events in the Coronary Tree II), a multicenter, prospective natural history study, patients with recent myocardial infarction underwent 3-vessel coronary angiography with coregistered near-infrared spectroscopy and intravascular ultrasound after successful percutaneous coronary intervention of obstructive lesions from 2014 through 2017. Two-feature high-risk plaques were defined as those with both plaque burden ≥70% and maximum lipid core burden index over any 4-mm segment ≥324.7. The primary end point was major adverse cardiovascular events arising from untreated nonculprit lesions during a median 3.7-year follow-up.
Of 898 patients, 199 (22.2%) with 849 nonculprit lesions had STEMI and 699 (77.8%) with 2784 nonculprit lesions had NSTEMI. By intravascular ultrasound, the median nonculprit lesion length was 17.4 mm (interquartile range, 16.3-18.5) in STEMI and 17.7 mm (interquartile range, 17.1-18.4) in NSTEMI (=0.63), and the median minimal lumen area was 5.5 mm (interquartile range, 5.3-5.7 mm) in STEMI and 5.5 mm (interquartile range, 5.3-5.6 mm) in NSTEMI (=0.99). At the lesion level, the prevalence of 2-feature high-risk nonobstructive nonculprit plaques was slightly higher in patients with STEMI than in patients with NSTEMI (12.8% versus 10.1%; =0.03). At the patient level, however, the prevalence of 2-feature high-risk plaques was similar in STEMI versus NSTEMI (38.8% versus 32.7%; =0.11). The prevalence of patients with 1 or more lesions meeting at least 1 high-risk plaque criterion was also similar (plaque burden ≥70%, 63.3% versus 57.8% [=0.16]; maximum lipid core burden index over any 4-mm segment ≥324.7, 63.3% versus 57.6% [=0.15]). The 4-year rates of nonculprit lesion-related major adverse cardiovascular events were similar in STEMI versus NSTEMI (8.6% versus 7.8%; hazard ratio, 1.02 [95% CI, 0.57-1.81]; =0.95), as were the rates of all major adverse cardiovascular events (14.2% versus 13.0%; hazard ratio, 1.06 [95% CI, 0.68-1.64]; =0.80).
In the PROSPECT II study, the per-patient prevalence of high-risk vulnerable plaques was comparable in STEMI versus NSTEMI, as was the overall long-term incidence of nonculprit lesion-related and all major adverse cardiovascular events. These results support a similar revascularization strategy for nonculprit lesions in patients with STEMI or NSTEMI after culprit lesion management.
URL: https://www.clinicaltrials.gov; Unique identifier: NCT02171065.
临床指南针对ST段抬高型心肌梗死（STEMI）与非ST段抬高型心肌梗死（NSTEMI）患者的非罪犯病变推荐了不同的血运重建策略。未经治疗的高危易损斑块在STEMI和NSTEMI中的患病率是否不同以及是否会影响其预后尚不清楚。
在PROSPECT II（提供区域观察以研究冠状动脉树中事件的预测因素II）这一多中心前瞻性自然史研究中，2014年至2017年期间，近期心肌梗死患者在成功对阻塞性病变进行经皮冠状动脉介入治疗后，接受了三支血管冠状动脉造影，并同步进行了近红外光谱和血管内超声检查。具有两个特征的高危斑块定义为斑块负荷≥70%且在任何4毫米节段上的最大脂质核心负荷指数≥324.7的斑块。主要终点是在中位3.7年随访期间未经治疗的非罪犯病变引发的主要不良心血管事件。
898例患者中，199例（22.2%）有849个非罪犯病变的患者发生STEMI，699例（77.8%）有2784个非罪犯病变的患者发生NSTEMI。通过血管内超声检查，STEMI患者非罪犯病变的中位长度为17.4毫米（四分位间距，16.3 - 18.5），NSTEMI患者为17.7毫米（四分位间距，17.1 - 18.4）（P = 0.63）；STEMI患者的中位最小管腔面积为5.5平方毫米（四分位间距，5.3 - 5.7平方毫米），NSTEMI患者为5.5平方毫米（四分位间距，5.3 - 5.6平方毫米）（P = 0.99）。在病变层面，具有两个特征的高危非阻塞性非罪犯斑块在STEMI患者中的患病率略高于NSTEMI患者（12.8%对10.1%；P = 0.03）。然而，在患者层面，具有两个特征的高危斑块在STEMI和NSTEMI中的患病率相似（38.8%对32.7%；P = 0.11）。有1个或更多病变符合至少1项高危斑块标准的患者患病率也相似（斑块负荷≥70%，63.3%对57.8% [P = 0.16]；在任何4毫米节段上的最大脂质核心负荷指数≥324.7，63.3%对57.6% [P = 0.15]）。非罪犯病变相关的主要不良心血管事件的4年发生率在STEMI和NSTEMI中相似（8.6%对7.8%；风险比，1.02 [95% CI，0.57 - 1.81]；P = 0.95），所有主要不良心血管事件的发生率也相似（14.2%对13.0%；风险比，1.06 [95% CI，0.68 - 1.64]；P = 0.80）。
在PROSPECT II研究中，STEMI和NSTEMI患者中高危易损斑块的患者患病率相当，非罪犯病变相关和所有主要不良心血管事件的总体长期发生率也相当。这些结果支持在处理罪犯病变后，对STEMI或NSTEMI患者的非罪犯病变采用相似的血运重建策略。
