Low-Attenuation Noncalcified Plaque on Coronary Computed Tomography Angiography Predicts Myocardial Infarction

Abstract

Background: The future risk of myocardial infarction is commonly assessed using cardiovascular risk scores, coronary artery calcium score, or coronary artery stenosis severity. We assessed whether noncalcified low-attenuation plaque burden on coronary CT angiography (CCTA) might be a better predictor of the future risk of myocardial infarction. Methods: In a post hoc analysis of a multicenter randomized controlled trial of CCTA in patients with stable chest pain, we investigated the association between the future risk of fatal or nonfatal myocardial infarction and low-attenuation plaque burden (% plaque to vessel volume), cardiovascular risk score, coronary artery calcium score or obstructive coronary artery stenoses. Results: In 1769 patients (56% male; 58±10 years) followed up for a median 4.7 (interquartile interval, 4.0–5.7) years, low-attenuation plaque burden correlated weakly with cardiovascular risk score ( r =0.34; P <0.001), strongly with coronary artery calcium score ( r =0.62; P <0.001), and very strongly with the severity of luminal coronary stenosis (area stenosis, r =0.83; P <0.001). Low-attenuation plaque burden (7.5% [4.8–9.2] versus 4.1% [0–6.8]; P <0.001), coronary artery calcium score (336 [62–1064] versus 19 [0–217] Agatston units; P <0.001), and the presence of obstructive coronary artery disease (54% versus 25%; P <0.001) were all higher in the 41 patients who had fatal or nonfatal myocardial infarction. Low-attenuation plaque burden was the strongest predictor of myocardial infarction (adjusted hazard ratio, 1.60 (95% CI, 1.10–2.34) per doubling; P =0.014), irrespective of cardiovascular risk score, coronary artery calcium score, or coronary artery area stenosis. Patients with low-attenuation plaque burden greater than 4% were nearly 5 times more likely to have subsequent myocardial infarction (hazard ratio, 4.65; 95% CI, 2.06–10.5; P <0.001). Conclusions: In patients presenting with stable chest pain, low-attenuation plaque burden is the strongest predictor of fatal or nonfatal myocardial infarction. These findings challenge the current perception of the supremacy of current classical risk predictors for myocardial infarction, including stenosis severity. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01149590.

Effect of icosapent ethyl on progression of coronary atherosclerosis in patients with elevated triglycerides on statin therapy: final results of the EVAPORATE trial

“…A prior study concluded that in symptomatic patients, LAP burden was the strongest predictor of myocardial infarction. 19 …”

Effect of vessel wall segmentation on volumetric and radiomic parameters of coronary plaques with adverse characteristics

“…Many papers have showed, that volumetric plaque analysis has additive information regarding CAD severity, disease progression and prognostication. [1][2][3][4][5] However, Symons et al indicated that there are significant variations in plaque volumes within 30 days even when the same scanner settings are used. Hence, significantly larger sample sizes are needed to achieve statistical significance due to the large test-retest variation.…”

“…6,7 However, it seems, that even among readers with considerable experience, there is substantial variation in contouring which leads to differences in plaque volumes. Unfortunately, this difference is largest in case of low-attenuation noncalcified plaque volume, which is currently of major research interest as it correlates with multiple clinical outcomes, [1][2][3][4][5] and therefore is seen as a potential pharmaceutical target. 6,7 Radiomic analysis is a promising new technique which may have the potential to increase the diagnostic accuracy of coronary CTA to identify vulnerable.…”

“…Results indicate that plaque volumes have additive information regarding CAD severity, disease progression and prognostication beyond the clinically interpreted qualitative characteristics of the disease. [1][2][3][4][5] New drug trials have even defined changes in CT angiography (CTA) derived plaques volumes as surrogate clinical end-points to test the efficacy of novel lipid lowering therapies. 6,7 Atherosclerotic lesions with adverse plaque characteristics (APC) are major targets of novel therapies, as these have been shown to greatly increase the risk of future adverse cardiac events.…”

Coronary artery calcium in primary prevention

“…30 Non-calcified plaque burden has been identified as an important predictor of future adverse cardiac events, particularly among symptomatic patients. 31 However, in asymptomatic patients, the use of coronary CT angiography to assess non-calcified plaque has not been shown to improve cardiovascular risk assessment when added to calcium scoring. 32,33…”