Debate: Preventive coronary intervention for vulnerable plaque. The interventional cardiologist�s approach

QUESTION: We would like to know your interpretation of the PREVENT trial.1 Do you think it could change clinical practice regarding the treatment of vulnerable plaques? ANSWER: The PREVENT is the first clinical trial ever conducted with statistical power to detect clinical differences in preventive treatment with stent implantation in functionally non-significant vulnerable plaques (fractional flow reserve [FFR] > 0.80, obtained via intracoronary pressure wire).1 This trial included patients with vulnerable plaques diagnosed using various intracoronary imaging modalities, who were randomized to receive stent implantation or optimal medical therapy. Approximately 2000 out of the 5500 lesions evaluated in the study were functionally significant (FFR ≤ 0.80), while 1600 (45%) out the remaining functionally non-significant 3500 lesions had vulnerable plaque criteria and were included in the study. The primary endpoint at the 2-year follow-up—a composite of cardiac death, target vessel myocardial infarction, target vessel revascularization, or hospitalization for unstable angina—was observed in 0.4% of the intervention group and 3.4% of the control group (a statistically significant difference). Despite this favorable result, the PREVENT trial has important limitations that raise questions on the implementation of this practice in everyday life. First, more than 80% of the patients from the PREVENT trial were included with...