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Clinical Trial
. 2022 Aug 22;23(9):1210-1221.
doi: 10.1093/ehjci/jeab135.

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

Maia Osborne-Grinter  1 , Jacek Kwiecinski  1   2 , Mhairi Doris  1 , Priscilla McElhinney  3 , Sebastien Cadet  3 , Philip D Adamson  1   4 , Alastair J Moss  5 , Shirjel Alam  1 , Amanda Hunter  1 , Anoop S V Shah  6 , Nicholas L Mills  1   7 , Tania Pawade  1 , Chengjia Wang  1 , Jonathan R Weir-McCall  8 , Giles Roditi  9 , Edwin J R van Beek  1   10 , Leslee J Shaw  11 , Edward D Nicol  12   13 , Daniel Berman  3 , Piotr J Slomka  3 , David E Newby  1   10 , Marc R Dweck  1   10 , Damini Dey  3 , Michelle C Williams  1   10
Affiliations
Clinical Trial

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

Maia Osborne-Grinter et al. Eur Heart J Cardiovasc Imaging. .

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 < 0.001), but there was no statistically significant difference between those with medium, high, and very high CACS. Myocardial infarction occurred in 41 patients, 10% of whom had zero CACS. CACS >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.

Keywords: atherosclerotic plaque; computed tomography; computed tomography coronary angiography; coronary calcium score; low-attenuation plaque.

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Conflict of interest statement

Conflict of interest: D.D., P.S., S.C., and D.S.B. may receive software royalties from Cedars-Sinai Medical Center, and D.D., P.S., and D.S.B. have a patent. Outside the submitted work, E.v.B. reports personal fees from Aidence NV, Mentholatum, grants from Siemens Healthineers, and other from QCTIS, Astra Zeneca, and Roche Diagnostics. D.E.N. reports grants from Chief Scientist Office, British Heart Foundation, and Royal Bank of Scotland and personal fees from Toshiba during the conduct of the study. Outside the submitted work, P.J.S. reports grants from NIH, Siemens Medical Systems, and Amazon Web Services. The remaining authors have nothing to disclose.

Figures

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.
Figure 1
Figure 1
Quantitative assessment of atherosclerotic plaque burden on CCTA in patients stratified into coronary artery calcium risk groups. Median total plaque burden (top left), calcified plaque burden (top right), non-calcified plaque burden (bottom left), and low-attenuation plaque burden (bottom right) in different coronary artery calcium score groups. CACS, coronary artery calcium score.
Figure 2
Figure 2
Proportion of patients in different coronary artery calcium score groups with (A) low-attenuation plaque burden >4% and (B) with normal, non-obstructive or obstructive disease on CCTA. CACS, coronary artery calcium score.
Figure 3
Figure 3
Proportion of patients with events by coronary artery calcium groups including angiography, all revascularization, all late revascularization, late MACE, fatal or non-fatal myocardial infarction, and all-cause mortality. CACS, coronary artery calcium score; CHD, coronary heart disease; MACE, major adverse cardiovascular events; MI, myocardial infarction. P < 0.001 for all.
Figure 4
Figure 4
Cumulative incidence plot for late MACE (after the first year) and calcium score groups. MACE, major adverse cardiovascular event.
Figure 5
Figure 5
Computed tomography coronary angiogram images from a 61-year-old man with a coronary artery calcium score of zero but a heavy burden of atherosclerotic plaque, including a high low-attenuation plaque burden of 9%. (A) A 3D reconstruction of the left anterior descending coronary artery with lumen in blue, non-calcified plaque in red, and low-attenuation plaque in orange. Curved planar reformation (B) and cross-sectional images (C, D) of the left anterior descending coronary artery show a severe stenosis with non-calcified plaque (orange arrow, C) and an adjacent plaque with a heavy burden of low-attenuation plaque (blue arrow, D).
See this image and copyright information in PMC

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