Title : Vulnerable plaque stabilization with OMT vs preventive PCI

Background: This study demonstrates the recent strategy utilized in the management of vulnerable coronary plaques, with a major focus on the fact that instead of severe narrowed coronary arteries, plaque rupture is the major reason behind various STEMI events and sudden cardiac deaths. Vulnerable plaques are majorly highly non-obstructive inflamed lesions which are associated with huge risk of rupture. Due to this, conventional angiography technique, which majorly assess the vessel lumen, may not be utilized for the evaluation of coronary plaques that are highly susceptible to become future culprit lesions.  Various newer advanced tools such as NIRS, OCT, IVUS, PET and AI-based plaque analysis are helping in shifting clinical approach towards a prevention option centred on plaques susceptibility instead of a stenosis-focused model.

Methods: The presentation suggest recent understanding of imaging characteristics, vulnerable plaque biology, and clinical trial findings comparing the targeted preventive percutaneous coronary interventions with optimal medical therapy. Imaging-based plaque investigation is considered as crucial step in selection of lesions with high-risk, including fibrous-cap thickness, lipid content, plaque burden, low-attenuation plaque, activity of macrophages and inflammation molecular biomarkers. Therapeutic options reviewed include PCSK9 inhibitors, anti-inflammatory drugs, antithrombotic therapy, metabolic risk control, statins, and lifestyle changes, as well as local stabilization options such as bioresorbable scaffolds drug-eluting stents and drug-coated balloons.

Results: Current findings suggest OMT as the major therapeutic options for stabilization of vulnerable plaques. OMT can potentiate plaque regression, reduce the lipid burden and lead to rise in the fibrous-cap thickness. Preventive PCI may act as complementary option in selective patients by increasing plaque stability, reducing lipid-core exposure and mechanically sealing thin-cap fibroatheromas. Findings of various trials such as PREVENT, PROSPECT-ABSORB, DEBut-LRP and SECRIT demonstrates that imaging-guided preventive PCI is quite safer and feasible strategy, with clinical evidence of lipid burden reduction, fibrous cap thickening and significant improvement in plaque burden among lesions with high-risk. However various drawback still exists, such as plaque biology dynamic nature, relatively lower event rates among various plaques labeled as susceptible plaques and serious concerns about stent thrombosis, neoatherosclerosis, cost, restenosis and absence of mortality benefit when compared with OMT alone.

Conclusions: Effective management of vulnerable plaques is shifting towards a modified proactive option from a reactive approach with the objective to prevent the risk of plaque rupture. Integrated model has emerged as most balanced strategy that majorly targets the atherosclerosis diffuse biology with using the selective, imaging-guided local therapeutic interventions. Future clinical practices will majorly depend upon the precision prevention, guided by AI-based risk assessment, multimodality imaging, molecular diagnostics and more biologically guided clinical use of PCI.

Dr Rohit Mody is a highly accomplished interventional cardiologist, academic leader, and healthcare entrepreneur with a strong national and international footprint. He serves as CEO of Mody Harvard Institutes & Research Centres and holds senior leadership roles across the Park Group and Clearmedi Group of Hospitals. Dr Mody has authored 99 peer reviewed publications, 15 editorial board memberships, and is actively involved in guideline-oriented research. He is a regular faculty at multinational cardiology conferences, delivering lectures and live-case teachings worldwide. His work focuses on complex coronary interventions, innovation, education, and expanding equitable, high-quality cardiac care across India and beyond.