European heart journal. Cardiovascular Imaging, 25 4 2025, Pages jeaf093 CCTA-Derived Coronary Plaque Burden Offers Enhanced Prognostic Value Over CAC Scoring In Suspected CAD Patients. Dahdal J, Jukema RA, Maaniitty T, Nurmohamed NS, Raijmakers PG, Hoek R, Driessen RS, Twisk JWR, Bär S, Planken RN, van Royen N, Nijveldt R, Bax JJ, Saraste A, van Rosendael AR, Knaapen P, Knuuti J, Danad I
Aim
To assess the prognostic utility of coronary artery calcium (CAC) scoring and coronary computed tomography angiography (CCTA) - derived quantitative plaque metrics for predicting adverse cardiovascular outcomes.
Methods and results
The study enrolled 2,404 patients with suspected CAD but without prior history of CAD. All participants underwent CAC scoring and CCTA, with plaque metrics quantified using an artificial intelligence (AI)-based tool (Cleerly, Inc). Percent atheroma volume (PAV) and non-calcified plaque volume percentage (NCPV%), reflecting total plaque burden and the proportion of non-calcified plaque volume normalized to vessel volume, were evaluated. The primary endpoint was a composite of all-cause mortality and non-fatal myocardial infarction (MI). Cox proportional hazards models, adjusted for clinical risk factors and early revascularization, were employed for analysis.During a median follow-up of 7.0 years, 208 patients (8.7%) experienced the primary endpoint, including 73 cases of MI (3%). The model incorporating PAV demonstrated superior discriminatory power for the composite endpoint (AUC = 0.729) compared to CAC scoring (AUC = 0.706, p = 0.016). In MI prediction, PAV (AUC = 0.791) significantly outperformed CAC (AUC = 0.699, p < 0.001), with NCPV% showing the highest prognostic accuracy (AUC = 0.814, p < 0.001).
Conclusions
AI-driven assessment of coronary plaque burden enhances prognostic accuracy for future adverse cardiovascular events, highlighting the critical role of comprehensive plaque characterization in refining risk stratification strategies.
