EROSION Study Suggests Intravascular Imaging Identifies Some MI Patients Who Can Forego Stenting

September 6, 2016—More than one-quarter of myocardial infarction (MI) patients who are normally treated with stents to reopen their blocked arteries might be able to forgo this procedure and receive antithrombotic medications only, according to results of the EROSION (Effective Antithrombotic Therapy Without Stenting: Intravascular Optical Coherence Tomography-Based Management in Plaque Erosion) pilot study presented at the European Society of Cardiology’s ESC Congress 2016 held August 27–31 in Rome, Italy. The study was simultaneously published online by Haibo Jia, MD, et al in the European Heart Journal.

In the ESC announcement, Lead Investigator Ik-Kyung Jang, MD, commented that the findings suggest “a potentially major change in the treatment of a significant number of patients with acute coronary syndromes (ACS).” Dr. Jang, who is with Harvard Medical School, Massachusetts General Hospital in Boston, Massachusetts, continued, “If this conservative approach without a metallic stent or polymer scaffold proves to be effective and safe, it may become a new treatment paradigm for over a quarter of patients with ACS, thereby abrogating stent-related early and late complications.”

Dr. Jang advised that most cases (approximately 60%) of ACS are caused by plaque rupture, but plaque erosion is responsible for 25% to 44% of cases and has a distinctly different pathology that is amenable to antithrombotic therapy.

The study used optical coherence tomography to differentiate plaque erosion from plaque rupture in 405 ACS patients presenting at the emergency department and undergoing coronary angiography. Plaque erosion was identified as the underlying pathology in 103 (25.4%) patients, of whom 60 had a residual diameter stenosis of < 70% on angiography, TIMI flow grade of 3, and were stable without symptoms.

These patients were deemed suitable to receive antithrombotic medications alone without stent placement and were treated with dual-antiplatelet therapy (aspirin and ticagrelor), as well as the addition of a glycoprotein IIb/IIIa inhibitor in 63.6%.

Dr. Jang reported that at 1-month follow-up, 47 of the 60 patients (78.3%) met the primary endpoint of the study, which was a more than 50% reduction in the size of their clot, with 22 of these patients having no visible clot at all. Overall, clot volume decreased from 3.7 to 0.2 mm³, and minimal flow area increased from 1.7 to 2.1 mm². One patient died of gastrointestinal bleeding while on dual-antiplatelet therapy, and another one had no improvement in the stenotic artery at 1 month, with the decision to undergo percutaneous coronary intervention.

In conclusion, Dr. Jang stated, “Currently, all patients with ACS are uniformly treated with stenting regardless of underlying pathology. This study, for the first time, demonstrates that patients with ACS caused by erosion may benefit from a tailored therapy with antithrombotic medications. If we can identify ACS patients with erosion without an invasive procedure, those patients may be triaged to a conservative therapy pathway instead of invasive catheterization and stent implantation.”