Interventional cardiology has long been synonymous with acute treatments like angioplasty and stenting during heart attacks, but a paradigm shift is underway. Researchers worldwide are exploring how minimally invasive catheter-based techniques can prevent cardiovascular disease before it escalates. By targeting vulnerable plaques and physiological bottlenecks early, these strategies aim to avert myocardial infarctions and strokes, potentially transforming cardiology from reactive to proactive.

Full form: Percutaneous Coronary Intervention (PCI), a cornerstone of interventional cardiology, involves threading catheters through arteries to treat blockages. Traditionally used for secondary prevention—managing established coronary artery disease (CAD)—emerging evidence supports its role in primary and early secondary prevention, particularly for high-risk lesions.

Global Burden of Cardiovascular Disease: Why Prevention Matters

Cardiovascular diseases (CVDs) claim nearly 20 million lives annually, accounting for 32% of global deaths, with 85% due to heart attacks and strokes. Ischemic heart disease and stroke dominate, yet 80% of CVDs are preventable through risk factor control. In the US alone, CVD prevalence affects over 130 million adults, with rising obesity (40.1%) and diabetes (14.1%) fueling projections of increased events by 2050.

Interventional approaches address this by intervening on subclinical disease. Universities like Stanford and UCSD lead preventive cardiology programs integrating imaging and physiology to identify at-risk patients before symptoms arise.

Imaging Revolution: Detecting Vulnerable Plaques

Optical Coherence Tomography (OCT) and Intravascular Ultrasound (IVUS) reveal thin-cap fibroatheromas (TCFA)—plaques prone to rupture causing 70% of heart attacks. AI-enhanced quantitative coronary CT angiography (AI-QCT) now quantifies non-calcified, high-risk plaques, reclassifying risk and prompting preventive therapies.

At TCT 2025, AI-QCT highlighted its role in early intervention, reducing events by guiding statin intensification. Mount Sinai and Cleveland Clinic researchers emphasize serial imaging for monitoring plaque regression post-therapy.

The PREVENT Trial: Landmark Evidence for Preventive PCI

The PREVENT trial (Preventive PCI on Stenosis with Functionally Insignificant Vulnerable Plaque), led by Samsung Medical Center, randomized 1,606 stable CAD patients with non-flow-limiting (>50% angiographic stenosis, vulnerable features on IVUS/OCT) lesions to PCI plus optimal medical therapy (OMT) vs. OMT alone. At 2 years, preventive PCI slashed target vessel failure by 46% (0.54 OR), driven by fewer spontaneous MIs. Meta-analyses confirm this, showing preventive PCI in vulnerable plaques cuts major adverse cardiac events (MACE).PREVENT full results

• Reduced TVF: 4.5% vs. 8.6%
• Spontaneous MI: 0.5% vs. 2.4%
• No increase in bleeding or stent thrombosis

University collaborations, including Asan Medical Center, validate this shift, positioning preventive PCI as standard for high-risk anatomy.

Physiological Guidance: FFR and iFR in Stable CAD

Fractional Flow Reserve (FFR)—measuring pressure drop across stenoses—guides selective PCI. FAME trials showed FFR-guided PCI in stable CAD reduces MACE by 30% vs. angiography alone, preventing unnecessary stenting. iFR (instantaneous wave-free ratio), non-hyperemic alternative, matched FFR in iFR-SWEDEHEART.

Long-term data: FFR-PCI improves quality-of-life and economics, averting events in multivessel disease.FAME 2 trial European and US universities like KU Leuven and Erasmus MC pioneered these, now guideline-recommended (Class IA).

Drug-Coated Balloons and Bioadaptors: Less Metal, More Prevention

SELUTION DeNovo (TCT 2025) proved sirolimus drug-coated balloons (DCBs) noninferior to stents in de novo lesions, promoting "leave-nothing-behind" to prevent late thrombosis. DynamX Bioadaptor halves target lesion failure post-6 months by unlocking after resorption.

These suit preventive strategies in small vessels/bifurcations, reducing chronic scaffold issues. Swedish and US trials underscore long-term benefits.

Renal Denervation: Interventional Hypertension Control

Resistant hypertension drives CVD; renal denervation (RDN)—catheter ablation of renal nerves—lowers SBP by 5-10 mmHg durably (SYMPLICITY trials). ASPC 2025 reaffirmed safety/efficacy as adjunct to meds. Universities like Columbia and UNC advance RDN variants (ultrasound, alcohol-mediated).

University Research Driving Innovation

Stanford's Preventive Cardiology Section integrates FFR/OCT for risk prediction. UCSD's Preventive Group runs trials on lifestyle + imaging. Mount Sinai's AI-QCT refines prevention. Global: Asan (Korea) PREVENT; KU Leuven (Belgium) FAME.

These programs train fellows in preventive interventional techniques, bridging cath labs and clinics.

Photo by Natanael Melchor on Unsplash

Challenges and Future Outlook

Barriers: Cost, access, over-intervention risks (ORBITA). Future: AI plaque analysis, bioresorbable scaffolds, PE response teams (STORM-PE). PREVENT-like trials expand to primary prevention.

Towards zero events: Interventional cardiology evolves, preventing disease via precision.