Systematic review on the effects of drug-coated balloon therapy on plaque morphology in patients with acute coronary syndrome

Background
In the treatment of diseased coronary arteries, drug-coated balloons (DCBs) have emerged as a “leave nothing behind” alternative to drug-eluting stents, yet their effects on coronary plaque morphology in Acute Coronary Syndromes (ACS) are not well characterised. This systematic review evaluates the impact of DCB therapy on plaque morphology in patients presenting with ACS.
Method
A systematic search of PubMed, Cochrane Library, Scopus, and ScienceDirect identified studies reporting plaque-related outcomes following DCB treatment in adult patients with ACS. Six studies met the inclusion criteria, incorporating intravascular ultrasound (IVUS), optical coherence tomography (OCT), near-infrared spectroscopy (NIRS) or angiographic assessments of plaque burden, plaque volume, plaque area, lipid burden, or calcification.
Results
Across comparative and non-comparative studies, DCB therapy was consistently associated with favourable imaging changes, including reductions in plaque area, plaque burden, or plaque atheroma volume, and increased lumen dimensions. In studies assessing compositional characteristics, DCB therapy was linked with reductions in lipid core burden and lower calcification scores compared with stent-based strategies. However, heterogeneity in study design, imaging methods, and outcome reporting limits direct comparison between studies, and causality cannot be conclusively inferred.
Conclusion
Available evidence suggests that DCB therapy may favourably modify plaque morphology in ACS, influencing plaque size and composition. The potential for DCBs to promote plaque regression, reduce lipid burden, and facilitate positive vascular remodelling warrants further investigation in larger, dedicated ACS cohorts. Future studies integrating advanced imaging and molecular profiling may clarify mechanistic pathways and identify patient groups most likely to benefit from DCB-based strategies.