HRPs increase the likelihood of adverse cardiovascular events, yet conventional risk scores often fail to detect them. A pooled analysis of the prospective COMBINE (OCT-FFR) and PECTUS-obs studies, published in EuroIntervention, evaluated the prognostic impact of HRPs across varying clinical risk profiles.

The study included 810 patients stratified into low, intermediate, and high clinical risk categories using a modified Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS-2P). OCT was used to identify HRPs, while major adverse cardiovascular events (MACE) and target lesion failure (TLF) were assessed at patient and lesion levels.

Clinical risk scores showed poor discrimination for HRP detection (area under the curve, 0.51; 95% confidence interval, 0.47 to 0.56). HRPs were consistently linked to worse outcomes across all risk groups. High-risk patients with HRPs had the highest event rate for TLF (6.28 per 100 lesion-years), corresponding to a 13.6% absolute risk at two years.

These results highlight the independent prognostic value of OCT-derived plaque characteristics beyond traditional risk assessment. The high event rates among patients with HRPs support the need for refined imaging-based strategies and targeted interventions to mitigate residual cardiovascular risk.