Location-specific prognostic significance of plaque burden, stenosis, and plaque morphology in coronary artery disease

Aims To investigate the location-specific prognostic significance of plaque burden, diameter stenosis, and plaque morphology. Methods and results Patients without a documented cardiac history that underwent coronary computed tomography angiography (CCTA) for suspected coronary artery disease were included. Percentage atheroma volume (PAV), maximum diameter stenosis, and plaque morphology were assessed and classified into proximal, mid, or distal segments of the coronary tree. Major adverse cardiac events (MACE) were defined as death or non-fatal myocardial infarction. Among 2819 patients 267 events (9.5%) occurred during a median follow-up of 6.9 years. When adjusted for traditional risk factors and the presence of PAV in other locations, only proximal PAV was independently associated with MACE. However, PAV of the proximal segments was strongly correlated to PAV localized at the mid (R = 0.76) and distal segments (R = 0.74, P < 0.01 for both). When only adjusted for cardiovascular risk factors, the area under the curve (AUC) to predict MACE for proximal PAV was 0.73 (95% CI 0.69-0.76), which was similar compared with mid PAV (AUC 0.72, 95% CI 0.68-0.76) and distal PAV (AUC 0.72, 95% CI 0.68-0.76). Similar results were obtained using diameter stenosis instead of PAV. The presence of proximal low-attenuation plaque had borderline additional prognostic value. Conclusion Proximal PAV was the strongest predictor of MACE when adjusted for cardiovascular risk factors and plaque at other locations. However, when the presence of plaque was only adjusted for cardiovascular risk factors, proximal, mid, and distal plaque localization showed a similar predictive ability for MACE. [Graphical Abstract]