Modern developments in coronary stent technology have dramatically reduced the rate of restenosis. However, late-phase stent failure remains a concern even with contemporary drug-eluting stents (DES). Several factors can cause stent failure, and one of the main mechanisms underlying this is neoatherosclerosis (NA)1,2. NA is characterized by accumulation of lipid-laden foamy macrophages within the neointima with or without necrotic core formation and/or calcification in pathological reports1,2.

Previous studies using optical coherence tomography (OCT) have shown that a high percentage of cases point to NA being responsible for both the occurrence of stent failure and the adverse long-term clinical outcomes3, 4, 5, 6. The strongest risk factors for NA development are high circulating levels of low-density lipoprotein cholesterol (LDL-C) and C-reactive protein3,4. Statins, LDL-C-lowering medications, are recommended to reduce the subsequent risk of major adverse cardiovascular events (MACE) in patients with coronary artery disease (CAD)7. Based on the current guidelines, the suggested target level for LDL-C is less than 70 mg/dL for secondary prevention in patients with acute coronary syndrome (ACS)8. However, despite reduction in LDL-C levels with statins, substantial residual risk persists, with the majority of predicted first and recurrent MACE not being averted9.

A meta-analysis of eight randomized controlled trials of statins reported that the on-treatment levels of non-high-density lipoprotein cholesterol (non-HDL-C) were more strongly associated with MACE than those of LDL-C and apolipoprotein B (apoB) in statin-treated patients10. Non-HDL-C comprises both LDL-C and triglyceride (TG)-rich lipoprotein cholesterol (TRL-C), such as very-low-density lipoprotein and remnant lipoprotein cholesterol. A previous study has suggested that the accumulation of triglyceride-rich lipoprotein (TRL) poses a residual risk in patients receiving effective statin therapy11.

OCT is a high-resolution imaging modality with the capacity to investigate detailed vascular healing after stent implantation. Additionally, it can evaluate plaque morphology with a sensitivity close to histology12. Moreover, OCT has been used to characterize different tissue patterns and it can generate distinct patterns of in-stent hyperplasia, such as NA13. This study aimed to investigate the association of lipid markers with NA in the early phase by performing OCT in patients undergoing statin treatment after percutaneous coronary intervention (PCI).