Calcified nodule as a distinct morphological risk factor after intravascular ultrasound-guided percutaneous coronary intervention.

Calcified nodules (CN) are recognized as high-risk morphological features; however, their prognostic impact on stable angina pectoris (SAP) in the contemporary era of intensive lipid-lowering therapy and advanced lesion preparation remains unclear. A total of 322 patients with SAP (450 procedures) who underwent elective intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) were analyzed. CN was identified in 40 patients (12%) at the patient level and in 61 lesions (14%) at the lesion level. The primary endpoint was clinically driven target lesion revascularization (TLR) at the lesion level. All patients received statin therapy following the index PCI. The CN group had higher prevalences of hypertension and hemodialysis and lower estimated glomerular filtration rate than the non-CN group, whereas age, diabetes mellitus, chronic kidney disease, left ventricular ejection fraction, low-density lipoprotein cholesterol (LDL-C), estimated small dense LDL-C (Esd LDL-C), and statin use did not differ significantly between groups. Kaplan-Meier analysis demonstrated a significantly higher cumulative incidence of major adverse cardiocerebrovascular events (MACCE) (p = 0.007) and clinically driven TLR at both patient (p = 0.005) and lesion levels (p < 0.001) in the CN group than in the non-CN group. In multivariable Cox regression adjusting for baseline clinical and procedural variables, CN remained independently associated with TLR (hazard ratio [HR]: 3.63, 95% confidence interval [CI] 1.62-8.14, p = 0.002) and MACCE (HR: 2.59, 95% CI 1.14-5.87, p = 0.023), whereas neither LDL-C nor other lipid parameters independently predicted outcomes. The drug-eluting stent (DES) strategy was independently associated with a lower risk of TLR (HR: 0.25, p = 0.002). In patients with SAP undergoing elective IVUS-guided PCI, all of whom received statin therapy following the index PCI, CN was independently associated with adverse clinical outcomes irrespective of baseline LDL-C or other lipid parameters. These findings suggest that CN represents a distinct high-risk morphological phenotype associated with adverse outcomes after PCI. In the overall cohort, DES use was independently associated with lower TLR than DCB use, although the optimal device strategy for CN lesions warrants further investigation. IVUS-based plaque characterization is essential and may facilitate morphology-oriented risk stratification in contemporary PCI practice.