Phenotyping Coronary Plaque by Computed Tomography in Premature Coronary Artery Disease

Eur Heart J Cardiovasc Imaging. 2023 Aug 19:jead212. doi: 10.1093/ehjci/jead212. Online ahead of print.


Aims: Premature coronary artery disease (CAD) is an aggressive disease with multiple recurrences mostly related to new coronary lesions. This study aimed to compare coronary plaque characteristics of individuals with premature CAD with those of incidental plaques found in matched individuals free of overt cardiovascular disease, using coronary computed tomography angiography (CCTA).

Methods and results: Of 1552 consecutive individuals who underwent CCTA, 106 individuals with history of acute or stable obstructive CAD ≤45 years were matched by age, sex, smoking status, cardiovascular heredity, and dyslipidemia with 106 controls. CCTA were analyzed for CAD-RADS score, plaque composition, and high-risk plaque features (HRP), including spotty calcification, positive remodeling, low-attenuation, and napkin-ring sign. The characteristics of 348 premature CAD plaques were compared with those of 167 incidental coronary plaques of matched controls. The prevalence of non-calcified plaques was higher among individuals with premature CAD (65.1% vs. 30.2%, p < 0.001), as well as spotty calcification (42.5% vs. 17.9%, p < 0.001), positive remodeling (41.5% vs. 9.4%, p < 0.001), low-attenuation (24.5% vs. 3.8%, p < 0.001) and napkin-ring sign (1.9% vs. 0.0%). They exhibited an average of 2.2[2.7] HRP, while the control group displayed 0.4[0.8] HRP (p < 0.001). Within a median follow-up of 24[16,34] months, individuals with premature CAD and ischemic recurrence (n = 24) had more HRP (4.3[3.9]) than those without ischemic recurrence (1.5[1.9]), mostly non-calcified with low-attenuation and positive remodeling.

Conclusion: Coronary atherosclerosis in individuals with premature CAD is characterized by a high and predominant burden of non-calcified plaque and unusual high prevalence of HRP, contributing to disease progression with multiple recurrences. A comprehensive qualitative CCTA assessment of plaque characteristics may further risk stratify our patients, beyond cardiovascular risk factors.

Keywords: Premature coronary artery disease; coronary computed tomography angiography; high-risk plaque; non-calcified plaque.