Coronary Atherosclerotic Plaque Regression

JACC State-of-the-Art Review

Luke P. Dawson, MBBS, MPH; Mark Lum, MBBS; Nitesh Nerleker, MBBS, PHD; Stephen J. Nicholls, MBBS, PHD; Jamie Layland, MBCHB, PHD

Disclosures

J Am Coll Cardiol. 2022;79(1):66-82. 

In This Article

Abstract and Introduction

Abstract

Over the last 3 decades there have been substantial improvements in treatments aimed at reducing cardiovascular (CV) events. As these treatments have been developed, there have been parallel improvements in coronary imaging modalities that can assess plaque volumes and composition, using both invasive and noninvasive techniques. Plaque progression can be seen to precede CV events, and therefore, many studies have longitudinally assessed changes in plaque characteristics in response to various treatments, aiming to demonstrate plaque regression and improvements in high-risk features, with the rationale being that this will reduce CV events. In the past, decisions surrounding treatments for atherosclerosis have been informed by population-based risk scores for initiation in primary prevention and low-density lipoprotein cholesterol levels for titration in secondary prevention. If outcome data linking plaque regression to reduced CV events emerge, it may become possible to directly image plaque treatment response to guide management decisions.

Introduction

Cardiovascular (CV) events relating to atherosclerotic plaque are the leading cause of mortality and morbidity globally.[1] Over the last few decades there have been remarkable advances in both imaging modalities that can be used to assess coronary plaque and the treatments available to slow progression and induce plaque regression. The primary aim in the development of novel treatments has been to demonstrate improvements in CV events in large outcome-based trials. Many trials have also assessed the mechanisms of improved outcomes by imaging changes in coronary plaque volumes and composition in response to treatment, with statins being the most well studied. This review focuses on the novel treatment strategies that may induce atherosclerotic plaque regression, and the imaging modalities that can assess changes in plaque volumes and composition. Further, we suggest that as coronary imaging improves, it may become feasible and highly beneficial to use a direct assessment of atherosclerotic plaque to more accurately inform decisions regarding initiation and titration of treatments.

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