Plaque characteristics and long-term outcome of non-culprit plaque rupture in AMI patients

Abstract Background Non-culprit plaque rupture (PR) had widespread nature in patients with acute coronary syndrome, indicating generalized acute destabilization. However, morphological features and long-term outcomes of non-culprit PR in acute myocardial infarction (AMI) patients have not been systemically investigated. Objectives We aimed to investigate the pancoronary picture (plaque characteristics and location) and long-term outcomes of non-culprit PR in AMI patients. Methods From January 2017 to May 2019, 3757 non-culprit plaques were analyzed in 883 AMI patients treated by 3-vessel optical coherence tomography. Patients and lesions were divided into two groups based on the presence or absence of non-culprit PR. All patients enrolled were followed for up to four years. Results Non-culprit PR was found in 178 patients (20.2%) and 200 lesions (5.3%). Patients with non-culprit PR had a more non-culprit lesions (NCLs) (p < 0.001), diseased arteries (p < 0.001) and multi-vessel disease (p < 0.001) compared with patients without non-culprit PR, both in angiography and OCT analyses. In vulnerable plaque feature, non-culprit PR group had higher incidence of thin-cap fibroatheroma (TCFA) (p < 0.001; p < 0.001), minimal lumen area (MLA) < 3.5mm² (p = 0.004; p = 0.012), CLIMA-defined high-risk plaque (p < 0.001; p < 0.001), thrombus (p < 0.001; p < 0.001), lipid rich plaque (p < 0.001; p < 0.001), calcification (p < 0.001; p < 0.001), macrophage (p < 0.001; p < 0.001), microchannel (p < 0.001; p < 0.001), cholesterol crystals (p < 0.001; p < 0.001), and layered tissue (p < 0.001; p < 0.001) compared with the other group, in patient and lesion level. In addition, non-culprit PR was highly populated at "hot spots" in the right coronary artery (56.5% vs. 40.2%; p < 0.001), and the originally treated culprit artery (33.5% vs. 25.2%; p = 0.008), and tended to cluster proximal to the coronary ostium [26.1 (15.5-38.0) vs. 29.4 (15.8-44.5); p = 0.009]. Multivariate analysis identified the NCL in the initially treated culprit artery (odds ratio [OR]: 1.874, 95% confidence interval [CI]: 1.230–2.857, p = 0.003), distance from coronary ostium to MLA site (OR: 0.987, 95% CI: 0.978–0.997, p = 0.008), mean lipid arc (OR: 1.006, 95% CI: 1.003–1.010, p = 0.001), TCFA (OR: 15.870, 95% CI: 10.259–24.551, p < 0.001), thrombus (OR: 4.333, 95% CI: 2.346–8.003, p < 0.001), and microchannel (OR: 1.679, 95% CI: 1.136–2.482, p = 0.009) were independent predictors of non-culprit PR. Non-culprit PR showed higher 4-year rates of NCL-related major adverse cardiac events in the patient (14.0% vs. 5.1%; p = 0.001) and lesion (6.5% vs. 0.9%; p < 0.001) levels. Conclusions NCLs with non-culprit PR had a unique pancoronary picture (pancoronary vulnerability and "hot spots") and worse long-term outcomes in AMI patients.