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Non-obstructive high-risk plaques increase the risk of future culprit lesions comparable to obstructive plaques
Richard A Ferraro1, Alexander R van Rosendael1,2, Yao Lu3
1Department of Radiology, New York-Presbyterian Hospital, Weill Cornell Medicine, 413 E 69th Street, Suite 108, New York, NY 10021, USA.
Insights
High-risk plaque (HRP) in coronary arteries, even when non-obstructive, significantly predicts future adverse events. These non-obstructive HRP lesions are common and carry substantial clinical risk.
Area of Science:
- Cardiology
- Radiology
- Biomedical Imaging
Background:
- High-risk plaque (HRP) and non-obstructive coronary artery disease are known predictors of adverse cardiovascular events.
- The independent contribution of HRP to the development of future culprit lesions in patients without acute coronary syndrome (ACS) remains unclear.
Purpose of the Study:
- To investigate the association between lesion percent diameter stenosis (%DS) and the prevalence/number of HRP in patients before confirmed ACS.
- To evaluate the relative importance of non-obstructive HRP in predicting future culprit lesions.
Main Methods:
- A nested case-control study within the ICONIC study using coronary computed tomographic angiography (coronary CT).
- Quantitative CT analysis to define obstructive (≥50% %DS) and non-obstructive (<50% %DS) lesions.
- HRP defined by ≥2 features: spotty calcification, positive remodeling, or low-attenuation plaque.
Main Results:
- Of 898 plaques in 234 patients with downstream ACS, 198 showed HRP. HRP was less prevalent in non-obstructive (19.7%) vs. obstructive (46.8%) lesions.
- Non-obstructive HRP lesions constituted 81.3% of all HRP lesions.
- In patients with identifiable culprit lesion precursors, HRP was associated with an adjusted hazard ratio of 1.85 (95% CI 1.26-2.72), irrespective of %DS.
Conclusions:
- Although HRP is more frequent in obstructive lesions, non-obstructive HRP lesions are more numerous and pose a significant clinical risk.
- The risk associated with non-obstructive HRP approaches that of obstructive lesions without HRP, highlighting their clinical importance.
Aims:
High-risk plaque (HRP) and non-obstructive coronary artery disease independently predict adverse events, but their importance to future culprit lesions has not been resolved. We sought to determine in patients prior to confirmed acute coronary syndrome (ACS) the association between lesion percent diameter stenosis (%DS), and the absolute number and prevalence of HRP. The secondary objective was to examine the relative importance of non-obstructive HRP in future culprit lesions.
Methods And Results:
Within the ICONIC study, a nested case-control study of patients undergoing coronary computed tomographic angiography (coronary CT), we included ACS cases with culprit lesions confirmed by invasive coronary angiography and coregistered to baseline coronary CT. Quantitative CT was used to evaluate obstructive (≥50%) and non-obstructive (<50%) diameter stenosis, with HRP defined as ≥2 features of spotty calcification, positive remodelling, or low-attenuation plaque at baseline. A total of 234 patients with downstream ACS over 54 (interquartile range 5-525.5) days exhibited 198/898 plaques with HRP on coronary CT. While HRP was less prevalent in non-obstructive (19.7%, 161/819) than obstructive lesions (46.8%, 37/79, P < 0.001), non-obstructive plaque comprised 81.3% (161/198) of HRP lesions overall. Among the 128 patients with identifiable culprit lesion precursors, the adjusted hazard ratio (HR) was 1.85 [95% confidence interval (CI) 1.26-2.72] for HRP, with no interaction between %DS and HRP (P = 0.82). Compared to non-obstructive HRP lesions, obstructive lesions without HRP exhibited a non-significant HR of 1.41 (95% CI 0.61-3.25, P = 0.42).
Conclusions:
While HRP is more prevalent among obstructive lesions, non-obstructive HRP lesions outnumber those that are obstructive and confer risk clinically approaching that of obstructive lesions without HRP.
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