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Cited by 565Cardiac Imaging and DiagnosticsCoronary Interventions and DiagnosticsAcute Myocardial Infarction Research

High-Risk Plaque Detected on Coronary CT Angiography Predicts Acute Coronary Syndromes Independent of Significant Stenosis in Acute Chest Pain

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Puchner, Stefan B., Liu, Ting, Mayrhofer, Thomas, Truong, Quynh A., Lee, Hang, Fleg, Jerome L., Nagurney, John T., Udelson, James E. +2 more·2014·Journal of the American College of Cardiology
DOI 10.1016/j.jacc.2014.05.039PMC PMC4135448
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Abstract

Background It is not known whether high-risk plaque, as detected by coronary computed tomography angiography (CTA), permits improved early diagnosis of acute coronary syndromes (ACS) independently to the presence of significant coronary artery disease (CAD) in patients with acute chest pain. Objectives The primary aim of this study was to determine whether high-risk plaque features, as detected by CTA in the emergency department (ED), may improve diagnostic certainty of ACS independently and incrementally to the presence of significant CAD and clinical risk assessment in patients with acute chest pain but without objective evidence of myocardial ischemia or myocardial infarction (MI). Methods We included patients randomized to the coronary CTA arm of the ROMICAT-II (Rule Out Myocardial Infarction/Ischemia Using Computer-Assisted Tomography II) trial. Readers assessed coronary CTA qualitatively for the presence of nonobstructive CAD (1% to 49% stenosis), significant CAD (≥50% or ≥70% stenosis), and the presence of at least 1 of the high-risk plaque features (positive remodeling, low <30 Hounsfield units plaque, napkin-ring sign, spotty calcium). In logistic regression analysis, we determined the association of high-risk plaque with ACS (MI or unstable angina pectoris) during the index hospitalization and whether this was independent of significant CAD and clinical risk assessment. Results Overall, 37 of 472 patients who underwent coronary CTA with diagnostic image quality (mean age 53.9 ± 8.0 years; 52.8% men) had ACS (7.8%; MI n = 5; unstable angina pectoris n = 32). CAD was present in 262 patients (55.5%; nonobstructive CAD in 217 patients [46.0%] and significant CAD with ≥50% stenosis in 45 patients [9.5%]). High-risk plaques were more frequent in patients with ACS and remained a significant predictor of ACS (odds ratio [OR]: 8.9; 95% CI: 1.8 to 43.3; p = 0.006) after adjustment for ≥50% stenosis (OR: 38.6; 95% CI: 14.2 to 104.7; p < 0.001) and clinical risk assessment (age, sex, number of cardiovascular risk factors). Similar results were observed after adjustment for ≥70% stenosis. Conclusions In patients presenting to the ED with acute chest pain but negative initial electrocardiogram and troponin, presence of high-risk plaques on coronary CTA increased the likelihood of ACS independent of significant CAD and clinical risk assessment (age, sex, and number of cardiovascular risk factors). (Multicenter Study to Rule Out Myocardial Infarction by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239).

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  • Non-calcified/mixed characteristics, a stenosis grade of ≥50%, and the proximal location of coronary plaques are established risk factors for ischaemic heart disease.

    “The non-calcified/mixed characteristics, a stenosis grade of ≥50%, and the proximal location of coronary plaques are all established risk factors for ischaemic heart disease.14,21”

    From Lifelong endurance exercise and its relation with coronary atherosclerosis (2023) · cites this paper as [21]

    The Results and Discussion (page unavailable) support ≥50% stenosis as a predictor of acute coronary syndrome and associate specific high-risk plaque features, including low attenuation, with it. They do not establish non-calcified or mixed composition as such a risk factor, nor do they address proximal plaque location. The study’s finding in patients with acute chest pain is also narrower than a general claim about ischaemic heart disease. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • Calcified plaques are considered more stable and less prone to rupture compared with mixed or non-calcified plaques, which are associated with a higher risk of adverse cardiovascular events.

    “as calcified plaques are considered more stable and less prone to rupture compared with mixed or non-calcified plaques, which are associated with a higher risk of adverse cardiovascular events.21 22”

    From Resting and exercise-induced occult hypertension and coronary atherosclerosis in male masters endurance athletes (2026) · cites this paper as [22]

    The Methods and Results identify low-attenuation non-calcified plaque as a high-risk feature, and the Discussion links high-risk features to acute coronary syndromes and future cardiovascular events (page unavailable). But the paper does not establish that calcified plaques generally are more stable or less prone to rupture than mixed or non-calcified plaques; it also identifies spotty calcium as a high-risk feature. It does not assess mixed plaques as a category. (LLM, conf=0.87)

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Authors
Puchner, S. B., Liu, T., Mayrhofer, T., Truong, Q. A., Lee, H., Fleg, J. L., Nagurney, J. T., Udelson, J. E., Hoffmann, U., & Ferencik, M.
Affiliations
  • Harvard University (US)
  • National Heart, Lung, and Blood Institute (US)
  • Tufts Medical Center (US)
Corresponding author
Ferencik, Maros
ORCID
Venue
Journal of the American College of Cardiology
Publisher
Elsevier BV
Published
2014-08
Volume
64
Issue
7
Pages
684-692
ISSN
0735-1097 (ISSN-L)
DOI
10.1016/j.jacc.2014.05.039
PMC
PMC4135448
OpenAlex
W109837811
Cited by
565
References
1
Citations by year
2026: 41 · 2025: 44 · 2024: 58 · 2023: 55 · 2022: 57 · 2021: 68 · 2020: 37 · 2019: 46 · 2018: 44 · 2017: 43 · 2016: 34 · 2015: 32 · 2014: 6
FWCI
29.99
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of the American College of Cardiology (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Heart, Lung, and Blood Institute (U01HL092022, K23HL098370, K24HL113128, U01HL092040, L30 HL093806)
Topics
  • Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
  • Health Sciences › Medicine › Surgery › Coronary Interventions and Diagnostics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Acute Myocardial Infarction Research
Keywords
vulnerable plaque, acute coronary syndrome, coronary CT angiography, acute chest pain, non-obstructive coronary artery disease, positive remodeling, napkin-ring sign, myocardial infarction, unstable angina, emergency department diagnosis, coronary artery stenosis, risk stratification
MeSH terms
Chest Pain, Female, Follow-Up Studies, Humans, Male, Middle Aged, Predictive Value of Tests, Prognosis, Retrospective Studies, Severity of Illness Index, Tomography, X-Ray Computed, Reproducibility of Results, Coronary Angiography, Risk Assessment, Coronary Stenosis, Acute Coronary Syndrome, Plaque, Atherosclerotic, Acute Pain

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