Relationship between culprit lesion high-risk plaque features and adverse cardiovascular outcome at two years follow-up in patients with acute coronary syndrome. Insights from the OPTICO-ACS study.

High-risk plaque features detected by optical coherence tomography (OCT) in culprit lesions (CL) of acute coronary syndrome (ACS) are linked to adverse cardiovascular outcomes. Whether the coexistence of multiple high-risk features within the same CL confers additional prognostic impact remains unknown. Within the multicentric, translational OPTICO-ACS study, the CL of 338 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 +) defined as a composite of cardiac death, non-fatal myocardial infarction, target vessel revascularization and re-hospitalization for progressive or unstable angina pectoris at two years follow-up. The relationship between each individual and multiple co-occurring high-risk features were comprehensively compared between patients with – and without clinical events. A ruptured fibrous cap [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 [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 (Triple Positive Plaque – TPP) within the same CL showed the strongest association with the primary endpoint (HR = 2.282 (1.462–3.562; p < 0.001). Adding TPP to baseline clinical risk, showed the strongest improvement in prediction accuracy for MACE + , as represented by an improvement in C-statistics of 0.056; p < 0.001. TPP showed the strongest association with the primary endpoint and significantly improved prediction accuracy for MACE + . This finding may support risk stratification after ACS and may justify enhanced secondary preventive measures.