From plaque to event: coronary plaque burden and morphology in predicting adverse cardiovascular outcomes

This study aimed to identify the association of plaque burden and morphological features, such as burden, length, and composition, with major adverse cardiovascular events (MACE) in populations with very high cardiovascular risk using coronary computed tomography angiography (CTA).

A retrospective cohort study was performed in Lithuania among stable symptomatic patients who underwent coronary CTA. All plaques were manually inspected using plaque analysis software. The study included 772 patients. The mean age was 59.6 ± 9.9 years in men and 65.2 ± 8.7 years in women (p < 0.001). Women exhibited relatively greater proportions of densely calcified plaque volume, whereas men demonstrated significantly higher proportions of fibrous, fibrofatty, and necrotic core volumes (all p < 0.001). Across cardiovascular risk categories, plaque burden, length, total plaque volume, and plaque dense calcium volume increased progressively from the lowest to the highest risk group (all p < 0.001). Among plaque characteristics, after adjusting plaque parameters for age, gender, and cardiovascular risk factors in the multivariable regression analysis, all analysed plaque parameters remained significant predictors of all MACE, with plaque burden, fibrofatty and necrotic core volumes being among the strongest (OR 1.048, 95% CI 1.038-1.059, OR 1.072, 95% CI 1.031-1.115, OR 1.056, 95% CI 1.003-1.111, respectively). Additionally, all analysed plaque characteristics, except fibrous volume, remained significant predictors of non-elective MACE. Plaque burden showed the strongest discrimination for all MACE (AUC 0.68; cut-off ≥17.8%) and non-elective MACE (AUC 0.64; cut-off ≥18.3%), while other plaque characteristics demonstrated modest but statistically significant discrimination value.

This study reveals that plaque morphology provides independent prognostic information. Among the studied very high cardiovascular risk population, patients with non-calcified plaque features-especially those with higher fibrofatty and necrotic core volumes-were the strongest independent predictors of MACE, whereas plaque burden provided the highest discriminatory performance for MACE, suggesting it's complementary role in risk assessment.