Symptom status and non-calcified plaque burden across CAC strata: insights from AI-based CCTA quantification

To investigate whether non-calcified coronary plaque (NCP) volume differs between symptomatic versus asymptomatic individuals across strata of coronary artery calcium (CAC) score, and whether symptom status adds incremental value beyond CAC. In this retrospective single-center study, we analyzed 1,835 adults (14% symptomatic, 86% asymptomatic) who underwent coronary CT angiography (CCTA) with AI-based plaque quantification. Participants were stratified into five CAC categories: 0, 1-99, 100-299, 300-1000, and > 1000 Agatston units. Total NCP volume was compared between symptomatic and asymptomatic patients within each stratum using non-parametric tests. Median NCP volumes were similar in both groups for CAC 0 (17.7 vs. 18.6 mm³, p = 0.96) and CAC 1-99 (50.8 vs. 56.3 mm³, p = 0.37). A significant difference emerged in the CAC 100-299 category: symptomatic patients had higher NCP (152.3 vs. 112.3 mm³, p = 0.035). No significant differences were seen in CAC 300-1000 or > 1000 (p = 0.12 and p = 0.066, respectively). Symptom status may be associated with higher non-calcified plaque burden particularly in symptomatic patients with CAC 100-299. Prospective outcome studies are needed to determine whether AI-quantified NCP volume can guide preventive therapy independent of CAC.