Invasive and non-invasive imaging and treatment of high-risk coronary lesions

Coronary artery disease (CAD) is globally one of the leading causes of death. It can present as stable CAD with invalidating angina symptoms or as acute coronary syndrome (ACS). Among the most severe forms of stable CAD is the chronic total occlusion (CTO), affecting about 20% of patients with CAD. This thesis elaborates on both ends of the spectrum of CAD.
Section I explores the outcomes of percutaneous coronary intervention (PCI) for a CTO, compared with medical therapy alone. The main finding is that CTO PCI primarily offers symptom relief, with no significant impact on exercise capacity, major adverse cardiovascular events , or long-term survival compared to medical therapy. Additionally, in post-ST-segment elevation myocardial infarction (STEMI) patients, CTO PCI was linked with increased risk of ventricular ectopy during exercise and a higher cardiovascular mortality, highlighting the need to carefully weigh symptom relief against potential risks.
In contrast to the uncertain indication of PCI for a CTO, PCI for ACS is life-saving and its indication is generally undisputed. Section II of the thesis examines imaging methods to detect high-risk lipid-rich plaques, which are prone to cause ACS, and evaluates potential treatment approaches. The findings indicate that local treatment of vulnerable plaques with paclitaxel-coated balloons can reduce the lipid-core burden of coronary plaques. This implies a potential method to stabilize high-risk plaques and decrease the recurrence of coronary events in ACS patients. This approach could be a promising way to reduce the risk and impact of repeat ACS through targeted interventions on high-risk plaques.