Low-Attenuation Noncalcified Plaque on Coronary Computed Tomography Angiography Predicts Myocardial Infarction: Results From the Multicenter SCOT-HEART Trial (Scottish Computed Tomography of the HEART)

Michelle C Williams, Jacek Kwiecinski, Mhairi Doris, Priscilla McElhinney, Michelle S D'Souza, Sebastien Cadet, Philip D Adamson, Alastair J Moss, Shirjel Alam, Amanda Hunter, Anoop S V Shah, Nicholas L Mills, Tania Pawade, Chengjia Wang, Jonathan Weir McCall, Michael Bonnici-Mallia, Christopher Murrills, Giles Roditi, Edwin J R van Beek, Leslee J Shaw, Edward D Nicol, Daniel S Berman, Piotr J Slomka, David E Newby, Marc R Dweck, Damini Dey, Michelle C Williams, Jacek Kwiecinski, Mhairi Doris, Priscilla McElhinney, Michelle S D'Souza, Sebastien Cadet, Philip D Adamson, Alastair J Moss, Shirjel Alam, Amanda Hunter, Anoop S V Shah, Nicholas L Mills, Tania Pawade, Chengjia Wang, Jonathan Weir McCall, Michael Bonnici-Mallia, Christopher Murrills, Giles Roditi, Edwin J R van Beek, Leslee J Shaw, Edward D Nicol, Daniel S Berman, Piotr J Slomka, David E Newby, Marc R Dweck, Damini Dey

Abstract

Background: The future risk of myocardial infarction is commonly assessed using cardiovascular risk scores, coronary artery calcium score, or coronary artery stenosis severity. We assessed whether noncalcified low-attenuation plaque burden on coronary CT angiography (CCTA) might be a better predictor of the future risk of myocardial infarction.

Methods: In a post hoc analysis of a multicenter randomized controlled trial of CCTA in patients with stable chest pain, we investigated the association between the future risk of fatal or nonfatal myocardial infarction and low-attenuation plaque burden (% plaque to vessel volume), cardiovascular risk score, coronary artery calcium score or obstructive coronary artery stenoses.

Results: In 1769 patients (56% male; 58±10 years) followed up for a median 4.7 (interquartile interval, 4.0-5.7) years, low-attenuation plaque burden correlated weakly with cardiovascular risk score (r=0.34; P<0.001), strongly with coronary artery calcium score (r=0.62; P<0.001), and very strongly with the severity of luminal coronary stenosis (area stenosis, r=0.83; P<0.001). Low-attenuation plaque burden (7.5% [4.8-9.2] versus 4.1% [0-6.8]; P<0.001), coronary artery calcium score (336 [62-1064] versus 19 [0-217] Agatston units; P<0.001), and the presence of obstructive coronary artery disease (54% versus 25%; P<0.001) were all higher in the 41 patients who had fatal or nonfatal myocardial infarction. Low-attenuation plaque burden was the strongest predictor of myocardial infarction (adjusted hazard ratio, 1.60 (95% CI, 1.10-2.34) per doubling; P=0.014), irrespective of cardiovascular risk score, coronary artery calcium score, or coronary artery area stenosis. Patients with low-attenuation plaque burden greater than 4% were nearly 5 times more likely to have subsequent myocardial infarction (hazard ratio, 4.65; 95% CI, 2.06-10.5; P<0.001).

Conclusions: In patients presenting with stable chest pain, low-attenuation plaque burden is the strongest predictor of fatal or nonfatal myocardial infarction. These findings challenge the current perception of the supremacy of current classical risk predictors for myocardial infarction, including stenosis severity. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01149590.

Keywords: atherosclerosis; cardiovascular diseases; computed tomography angiography; coronary artery disease; myocardial infarction; plaque, atherosclerotic.

Figures

Figure 1.
Figure 1.
Coronary CT angiography (CCTA) plaque analysis. Images from a 67-year-old female who presented with atypical chest pain. She was a nonsmoker with a history of hypertension, a previous transient ischemic attack, and normal exercise tolerance test. Her 10-year cardiovascular risk score was 14%, coronary artery calcium score was 62 Agatston units, and coronary computed tomography angiography identified obstructive disease in the left anterior descending (LAD) and first diagonal. Curved planar reformations show (A) proximal LAD, (B) first diagonal, and (C) mid-LAD. Red overlay illustrates noncalcified plaque in the individual segment only, but all plaque in each vessel was analyzed for the per patient assessment. D, Shows a zoomed in view of the mid LAD plaque with blue lumen, red noncalcified plaque and orange low-attenuation plaque. She subsequently presented with acute myocardial infarction and underwent invasive coronary angiography (E).
Figure 2.
Figure 2.
Correlations between plaque burden subtypes, calcium score, coronary stenosis and cardiovascular risk score. Correlations between plaque burden subtypes and Agatston coronary artery calcium score, coronary artery area stenosis and ASSIGN (Assessing cardiovascular risk using SIGN guidelines) cardiovascular risk score. P<0.001 for all. CACS indicates Agatston coronary artery calcium score.
Figure 3.
Figure 3.
Correlations between low-attenuation plaque burden, cardiovascular risk score, calcium score and coronary stenosis. Correlations between total low-attenuation plaque burden and 10-year cardiovascular risk score, Agatston coronary artery calcium score, and coronary artery area stenosis. CACS indicates Agatston coronary artery calcium score.
Figure 4.
Figure 4.
Plaque burden and fatal or nonfatal myocardial infarction. Quantitative assessment of atherosclerotic plaque burden in patients with and without a primary event of fatal or nonfatal myocardial infarction (P≤0.01 for all). CACS indicates Agatston coronary artery calcium score, and MI, myocardial infarction.
Figure 5.
Figure 5.
Low-attenuation plaque burden and fatal or nonfatal myocardial infarction. Cumulative incidence of fatal or nonfatal myocardial infarction in patients with and without a low-attenuation plaque burden greater than 4%. MI indicates myocardial infarction.

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