Lowering low-density lipoprotein cholesterol (LDL-C) below 55 mg/dL is a central target in current ESC guidelines, but not all patients achieve the same cardiovascular benefit. Findings from the REASSUR-NIRS registry, presented at the European Society of Cardiology (ESC) Congress 2025, highlight that plaque composition may determine treatment response.

The study evaluated patients with coronary artery disease who underwent PCI with intravascular imaging using near-infrared spectroscopy/intravascular ultrasound. Investigators developed the lipidic plaque density index (LPDI), a measure of lipid burden within atheroma, and stratified patients into low and high LPDI groups. Achieved LDL-C was assessed at three months, with <55 mg/dL as the target.

Patients with low LPDI reached the LDL-C target. However, they still showed no reduction in major adverse cardiovascular events. In contrast, those with high LPDI who reached LDL-C <55 mg/dL experienced a significant decline in major adverse cardiovascular events, including cardiac death, non-fatal myocardial infarction, and unplanned revascularization.

These findings suggest that imaging-guided lipid-lowering strategies may enable more personalized treatment and better allocation of intensive therapies.