The identification of high-risk plaque by coronary computed tomographic angiography (CTA) can help predict the long-term risk for major adverse cardiovascular events (MACE) in patients with stable chest pain, particularly in women or patients with nonobstructive coronary artery disease, according to a study analysis published in JAMA Cardiology.
Individuals with symptomatic disease (n=4415) with stable chest pain who participated in the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE; ClinicalTrials.gov identifier: NCT01174550) trial who received coronary CTA and were followed for a median of 25 months were included in this analysis. At study inclusion, patients had a MACE rate of 3% (131 events) and a median atherosclerotic cardiovascular disease risk score of 11.
High-risk plaque, which was present in 676 patients (15.3%), correlated with a higher MACE rate at follow-up compared with no high-risk plaque (6.4% vs 2.4%; hazard ratio, 2.73; 95% CI, 1.89-3.93). When investigators adjusted for both significant stenosis (SS) and atherosclerotic cardiovascular disease risk score, the association between high-risk plaque and greater long-term MACE risk persisted (adjusted hazard ratio [aHR], 1.72; 95% CI, 1.13-2.62).
In addition, patients with nonobstructive coronary artery disease who had high-risk plaque also had a higher risk for MACE compared with patients without high-risk plaque (aHR, 4.31 vs 2.64; 95% CI, 2.25-8.26 vs 1.49-4.69). Conversely, the investigators found no differences between patients with high-risk plaque and SS vs those with SS and no high-risk plaque in terms of MACE (aHR, 8.68 vs. 9.31; 95% CI, 4.25-17.73 vs 4.21-20.61).
Female gender (aHR, 2.41; 95% CI, 1.25-4.64) represented a strong MACE predictor compared with male gender (aHR, 1.40; 95% CI, 0.81-2.39) in the presence of high-risk plaque. In addition, high-risk plaque in younger patients (aHR, 2.33; 95% CI, 1.20-4.51) vs older patients (aHR, 1.36; 95% CI, 0.77-2.39) held greater predictive value for MACE risk.
This analysis did not evaluate therapy changes initiated by the identification of high-risk plaque, which may have influenced MACE risk. In addition, treatment for patients in the PROMISE trial was primarily based on coronary CTA findings, which may have also affected MACE.
Investigators of this analysis suggested that, “the low absolute rates of [MACE] and low positive predictive value of high-risk plaque detection might limit its clinical applicability” for predicting long-term risks in this patient population.
Ferencik M, Mayrhofer T, Bittner DO, et al. Use of high-risk coronary atherosclerotic plaque detection for risk stratification of patients with stable chest pain: a secondary analysis of the PROMISE randomized clinical trial [published online January 10, 2018]. JAMA Cardiol. doi:10.1001/jamacardio.2017.4973