High-risk plaques in non-culprit lesions and clinical outcome after NSTEMI vs. STEMI

Aims Complete non-culprit (NC) revascularisation may help reduce recurrent events after non-ST-segment elevation myocardial infarction (NSTEMI), especially if NC lesions would harbour high-risk plaque (HRP) features similar to ST-segment elevation myocardial infarction (STEMI). This study aimed to assess differences in fractional flow reserve (FFR)-negative NC plaque morphology in patients presenting with NSTEMI vs. STEMI and assess the association of HRP morphology and clinical outcome. Methods In the prospective PECTUS-obs study, 438 patients presenting with myocardial infarction (MI) underwent optical coherence and results tomography (OCT) of all FFR-negative intermediate NC lesions. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE, composite of all-cause mortality, non-fatal MI or unplanned revascularisation) at 2-year follow-up. Four hundred and twenty patients had at least one analysable OCT, including 203 (48.3%) with NSTEMI and 217 (51.7%) with STEMI. The prevalence of HRPs, including thin-cap fibroatheromas, plaque rupture, and thrombus, was comparable between groups. MACE occurred in 29 (14.3%) NSTEMI patients and 16 (7.4%) STEMI patients (P _uni-variable = 0.025 and P _{multi-variable} = 0.270). Incidence of MACE was numerically higher among patients with HRP, irrespective of the clinical presentation at index (P _interaction = 0.684). Among HRP criteria, plaque rupture was associated with MACE in both NSTEMI (P < 0.001) and STEMI (P = 0.020). Conclusion Presence of NC HRP is comparable between NSTEMI and STEMI and leads to numerically higher event rates in both. These results call for additional research on complete revascularisation in NSTEMI and treatment of HRP.