Great debate: preventive percutaneous coronary intervention added to optimal medical treatment should be the default treatment for non-flow-limiting vulnerable plaques

Acute myocardial ischaemic syndromes frequently arise from rupture or erosion of non-flow-limiting vulnerable plaques. Despite major advances in lipid-lowering and anti-inflammatory therapies, a substantial residual cardiovascular risk persists under optimal medical therapy, driving interest in preventive percutaneous coronary intervention (PCI) to stabilize these high-risk lesions. Contemporary intracoronary imaging techniques, including intravascular ultrasound, optical coherence tomography, and near-infrared spectroscopy, can identify plaques at greatest risk of rupture, and preventive PCI, as demonstrated in the PREVENT trial, may reduce composite outcomes of cardiac death, myocardial infarction, revascularization, and unstable angina compared with medical therapy alone. Sealing such plaques may prevent future acute coronary events, particularly in high-risk patients with multivessel disease. However, these benefits were driven mainly by softer endpoints observed in an open-label design, and were not accompanied by significant reductions in mortality or hard outcomes. Concerns remain regarding the procedural risks and cost-effectiveness of preventive PCI, and the impact of novel and more intensive lipid-lowering therapies in this clinical setting has not been adequately explored. Although preventive PCI represents an intriguing paradigm shift that challenges physiology-guided treatment strategies, further studies are needed to confirm its safety, durability, and incremental value over contemporary medical therapy. This Great Debate examines whether preventive PCI should be considered the default management strategy for non-flow-limiting vulnerable plaques.