Journal
CIRCULATION
Volume 141, Issue 18, Pages 1452-1462Publisher
LIPPINCOTT WILLIAMS & WILKINS
DOI: 10.1161/CIRCULATIONAHA.119.044720
Keywords
atherosclerosis; cardiovascular diseases; coronary artery disease; computed tomography angiography; myocardial infarction; plaque; atherosclerotic
Funding
- Chief Scientist Office of the Scottish Government Health and Social Care Directorates [CZH/4/588]
- Edinburgh and Lothian's Health Foundation Trust
- Heart Diseases Research Fund
- British Heart Foundation [FS/11/014, CH/09/002, RG/16/10/32375, RE/18/5/34216, FS/14/78/31020]
- Chief Scientist Office of the Scottish Government Health [PCL/17/04]
- Wellcome Trust Senior Investigator Award [WT103782AIA]
- Scottish Imaging Network: A Platform of Scientific Excellence (SINAPSE)
- National Heart Foundation of New Zealand Senior Fellowship [1844]
- Sir Jules Thorn Biomedical Research Award 2015 [15/JTA]
- Royal Bank of Scotland
- National Health Service Research Scotland (NRS) through National Health Service Lothian Health Board
- National Health Service Research Scotland (NRS)
- National Institute of Health/National Heart, Lung, and Blood Institute [1R01HL133616]
- Miriam and Sheldon G. Adelson Medical Research Foundation
- British Heart Foundation [RG/16/10/32375, FS/14/78/31020, CH/09/002/26360] Funding Source: researchfish
- Chief Scientist Office [CZH/4/588] Funding Source: researchfish
- Medical Research Council [G0701127] Funding Source: researchfish
- MRC [G0701127] Funding Source: UKRI
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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; 5810 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.
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