More people are likely to be diagnosed with a condition that increases the risk of heart attack and stroke due to a recent expansion in the definition of high-risk plaque. This condition was previously defined as plaque buildup in the arteries that is prone to rupture, potentially leading to an acute heart attack or sudden cardiac death. In the past, it was rarely diagnosed because identifying it required advanced imaging tests.
However, advancements in both treatment options and the understanding of high-risk plaque have grown significantly. A newly proposed definition, published in a leading cardiology journal, broadens the criteria for diagnosing high-risk plaque, which means more people may see this term on their imaging reports. Patients with access to their test results may become concerned when they see this diagnosis, leading to an influx of questions for their doctors about their risk of heart attack.
How a doctor responds to a high-risk plaque diagnosis varies. Most recommend medication and lifestyle changes to reduce plaque buildup. Others advocate for additional tests and diagnoses, which may lead to invasive procedures such as stent placement. While lifestyle modifications and medication can significantly reduce risk, the broader definition opens the possibility of unnecessary interventions, a concern among some experts.
High-risk plaque contributes to approximately 40% of acute coronary syndromes, including heart attacks and unstable angina. Among different types, thin-cap fibroatheroma plaque (TCFA) is considered the most dangerous due to its high risk of rupture. However, studies indicate that only 1% of TCFA plaques lead to acute myocardial infarction, meaning treating all detected cases with stents would result in many unnecessary procedures.
The broadened definition includes various imaging options for identifying high-risk plaque, such as CT scans. While CT scans often lack the detail needed for a firm diagnosis, they still play a role in detecting potential risks. Patients referred for further testing sometimes experience heightened anxiety, though not all detected plaques will lead to complications.
High-risk plaques are often compared to dormant volcanoes seemingly stable but with the potential to cause sudden, serious events if they rupture. Cardiologists debate whether more imaging and procedures will lead to better outcomes or unnecessary treatments.
There are three main types of high-risk plaques: TCFA, erosion-prone plaque, and eruptive calcified nodules. Erosion-prone plaque is a fibrous form that may or may not have significant lipid or cholesterol deposits. Instead of rupturing like TCFA, it becomes inflamed, leading to blood clot formation. Eruptive calcified nodules consist of irregular calcium deposits that cause turbulence in blood flow, increasing the likelihood of clotting.
Despite differing views on treatment, most experts agree that aggressive medical therapy is the foundation for managing high-risk plaque. This includes medication and lifestyle changes such as a healthy diet, exercise, and quality sleep. Doctors commonly prescribe statins alongside other drugs that lower cholesterol, reduce inflammation, or protect the heart, such as PCSK9 inhibitors, bempedoic acid, colchicine, ezetimibe, icosapent ethyl, and inclisiran. Research has shown that these therapies can stabilize and even reduce plaque buildup.
The debate over whether high-risk plaque should be treated with stents remains unresolved. Some argue that stents could be beneficial in stabilizing the plaque and preventing rupture. Preliminary studies suggest that stents may thicken the plaque cap, potentially making it less vulnerable. However, concerns remain that the expanded definition could lead to an increase in unnecessary stenting, as it is still unclear which plaques will rupture. Further studies are needed to determine if stenting high-risk plaques is a beneficial long-term approach.
While high-risk plaque presents a significant health concern, the best course of action remains aggressive medical therapy and lifestyle changes, with further research needed to determine if more invasive interventions are warranted
