Association of coronary artery calcium score with qualitatively and quantitatively assessed adverse plaque on coronary CT angiography in the SCOT-HEART trial

• Published in: European heart journal cardiovascular imaging 2022-08, Vol.23 (9), p.1210-1221
• Main Authors: Osborne-Grinter, Maia, Kwiecinski, Jacek, Doris, Mhairi, McElhinney, Priscilla, Cadet, Sebastien, Adamson, Philip D, Moss, Alastair J, Alam, Shirjel, Hunter, Amanda, Shah, Anoop S V, Mills, Nicholas L, Pawade, Tania, Wang, Chengjia, Weir-McCall, Jonathan R, Roditi, Giles, van Beek, Edwin J R, Shaw, Leslee J, Nicol, Edward D, Berman, Daniel, Slomka, Piotr J, Newby, David E, Dweck, Marc R, Dey, Damini, Williams, Michelle C
• Format: Article
• Language: English
• Subjects: Calcium; Computed Tomography Angiography - methods; Coronary Angiography - methods; Coronary Artery Disease - complications; Coronary Artery Disease - diagnostic imaging; Humans; Myocardial Infarction - complications; Original Paper; Plaque, Atherosclerotic - complications; Plaque, Atherosclerotic - diagnostic imaging; Predictive Value of Tests; Risk Assessment; Risk Factors; Tomography, X-Ray Computed; Vascular Calcification - complications; Vascular Calcification - diagnostic imaging
• ISSN: 2047-2404; 2047-2412
• DOI: 10.1093/ehjci/jeab135

Abstract Aims Coronary artery calcification is a marker of cardiovascular risk, but its association with qualitatively and quantitatively assessed plaque subtypes is unknown. Methods and results In this post-hoc analysis, computed tomography (CT) images and 5-year clinical outcomes were assessed in SCOT-HEART trial participants. Agatston coronary artery calcium score (CACS) was measured on non-contrast CT and was stratified as zero (0 Agatston units, AU), minimal (1–9 AU), low (10–99 AU), moderate (100–399 AU), high (400–999 AU), and very high (≥1000 AU). Adverse plaques were investigated by qualitative (visual categorization of positive remodelling, low-attenuation plaque, spotty calcification, and napkin ring sign) and quantitative (calcified, non-calcified, low-attenuation, and total plaque burden; Autoplaque) assessments. Of 1769 patients, 36% had a zero, 9% minimal, 20% low, 17% moderate, 10% high, and 8% very high CACS. Amongst patients with a zero CACS, 14% had non-obstructive disease, 2% had obstructive disease, 2% had visually assessed adverse plaques, and 13% had low-attenuation plaque burden >4%. Non-calcified and low-attenuation plaque burden increased between patients with zero, minimal, and low CACS (P 1000 AU and low-attenuation plaque burden were the only predictors of myocardial infarction, independent of obstructive disease, and 10-year cardiovascular risk score. Conclusion In patients with stable chest pain, zero CACS is associated with a good but not perfect prognosis, and CACS cannot rule out obstructive coronary artery disease, non-obstructive plaque, or adverse plaque phenotypes, including low-attenuation plaque. Graphical Abstract Graphical Abstract Coronary artery disease and high-risk plaque features are common in patients with zero or low coronary artery calcium score, and low-attenuation plaque burden (orange arrow) increases as the calcium score increases.