Artificial intelligence-based identification of thin-cap fibroatheromas and clinical outcomes: the PECTUS-AI study

Abstract Background and Aims Coronary thin-cap fibroatheromas (TCFA) are associated with adverse outcome, but identification of TCFA requires expertise and is highly time-demanding. This study evaluated the utility of artificial intelligence (AI) for TCFA identification in relation to clinical outcome. Methods The PECTUS-AI study is a secondary analysis from the prospective observational PECTUS-obs study, in which 438 patients with myocardial infarction underwent optical coherence tomography (OCT) of all fractional flow reserve-negative non-culprit lesions (i.e. target lesions). OCT images were analyzed for the presence of TCFA by an independent core laboratory (CL-TCFA) and OCT-AID, a recently developed and validated AI segmentation algorithm (AI-TCFA). The primary outcome was defined as the composite of death from any cause, non-fatal myocardial infarction or unplanned revascularisation at 2 years (±30 days), excluding procedural and stent-related events. Results Among 414 patients, AI-TCFA and CL-TCFA were identified in 143 (34.5%) and 124 (30.0%) patients, respectively. AI-TCFA within the target lesion was significantly associated with the primary outcome [hazard ratio (HR) 1.99, 95% confidence interval (CI) 1.02–3.90, P = .04], while the HR for CL-TCFA was non-significant (1.67, 95% CI: .84–3.30, P = .14). When evaluating the complete pullback, AI-TCFA showed an even stronger association with the primary outcome (HR 5.50, 95% CI: 1.94–15.62, P < .001; negative predictive value 97.6%, 95% CI: 94.0%–99.3%). Conclusions AI-based OCT image analysis allows standardized identification of patients at increased risk of adverse cardiovascular outcome, offering an alternative to manual image analysis. Furthermore, AI-assisted evaluation of complete imaged segments results in better prognostic discrimatory value than evaluation of the target lesion only.