Imaging of atherosclerotic plaque, particularly via CT scan, has improved immensely over the past decade in its ability to quantify plaque and discern plaque composition, particularly with advances in machine learning approaches to analysis. Here, researchers demonstrate that plaque volume correlates with risk of severe cardiovascular events. The volume of softer, more fatty plaque also correlates with risk, much as one might expect. It is these less stable plaques that are more likely to fragment, leading to a downstream blockage. Imaging will become more important as cardiovascular therapies improve to point of being able to produce rapid stabilization or even regression of plaque, capabilities that do not currently exist. The best that can be done with the present standard of care, focused on lowering LDL cholesterol, is a slowing of plaque growth and some degree of stabilization over years of sustained use.
Despite the increasing use of coronary computed tomographic angiography (CCTA) in patients with known or suspected coronary artery disease (CAD), comparatively little is known about its predictive value for adverse events or clinical applicability of volumetric plaque analysis. This post hoc analysis involved a prospective randomized clinical trial conducted across 193 clinical sites in North America. Participants were symptomatic outpatients without known CAD who were randomized to receive CCTA. Core laboratory-based quantitative plaque measures including total plaque volume (TPV), calcified (CPV) and noncalcified (NCPV) plaque volume, low-attenuation plaque volume (LAPV), total plaque burden (TPB), and noncalcified plaque burden (NCPB), normalized with vessel volume.
The primary outcome was major adverse cardiovascular events, MACE (composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina). Among 4,267 patients, the mean age was 60.4 ± 8.2 years; 2199 patients (51.5%) were female and 2068 (48.5%) were male. Higher total plaque volume (≥87 mm), total plaque burden (≥35%), and noncalcified plaque burden (≥20%) were associated with an increased risk of MACE, independent of atherosclerotic cardiovascular disease risk, statin use, 50% or more stenosis, coronary artery calcium score, and high-risk plaque.
Link: https://doi.org/10.1001/jamacardio.2025.5520
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