The panel expert raised the query regarding the sample size and the estimated 12% event rate. The basis for these figures was inquired about. Additionally, information was requested concerning the medical therapy these patients were receiving at the time and their average or mean low-density lipoprotein (LDL) levels. Due to its limited clinical relevance, there was limited interest in focusing on the imaging-defined nature of plaque. In real-world clinical practice, image-guided percutaneous coronary intervention (PCI) remains less than 10%, even with an emphasis on physiologically guided PCI, indicating limited adoption of physiological concepts. In terms of patient flow, all patients underwent fractional flow reserve (FFR) initially, with a surprisingly large number showing negative FFR results, exceeding 50% of lesions with significant stenosis. Within this subgroup, imaging-oriented evaluation was performed on a small proportion of plaques. Despite global interest, image-guided approaches have not been widely embraced. For remaining non-culprit vessels, imaging was prioritized to identify specific plaque patterns in a small subset. Previous studies and ongoing research suggest that focusing solely on adverse events associated with plaques may not capture all relevant risks. Therefore, a suggestion was made to prioritize physiological considerations, particularly when assessing patient and lesion subsets, with optional imaging evaluation to address specific patient concerns. These suggestions are essentially hypothetical proposals for guiding future practice. Another query was whether all the plaques mentioned are vulnerable or belong to patients with a large plaque burden. It was noted that over 97% of the patients met the criteria for large plaque burden and small minimal luminal area (MLA), while only a smaller subset exhibited abnormal entry criteria indicating true vulnerability as identified by near-infrared spectroscopy (NIRS) or thin-cap fibroatheroma (TCFA). The possibility of simplifying the assessment for future use was discussed, considering the impracticality of expecting every interventionalist to utilize multiple imaging modalities for moderate lesions. Grayscale intravascular ultrasound (IVUS) was suggested as potentially providing adequate assessment. Based on the presented data, practical concerns were highlighted regarding grayscale IVUS, indicating that it effectively assessed plaque burden and minimal luminal dimensions, making it easier to detect among various clinical characteristics. Further data and studies were deemed necessary to understand the influence of different clinical characteristics on clinical events.

American College of Cardiology (ACC) Congress 2024, 6th April – 8th April 2024, Atlanta, Georgia, USA