Coronary atherosclerosis: impact of plaque burden

Coronary artery disease (CAD) progresses over many years before becoming evident from a clinical standpoint. In this context, the assessment of the risk of future events is critical for optimal patients management.
The first-line diagnostic test for patients with suspected CAD recommended by many stakeholders in the field Is computed tomography angiography (CTA) as it provides detailed information on CAD severity.
MB Mortensen and colleagues tried to evaluate if obstructive CAD provides predictive value beyond its association with total calcified atherosclerotic plaque burden as assessed by coronary artery calcium.
They reviewed data of 23,759 symptomatic patients from the Western Denmark Heart Registry who underwent diagnostic computed tomography angiography (CTA), trying to analyse the risk of major cardiovascular disease (CVD) including myocardial infarction, stroke, and all cause death, stratified by coronary artery calcium burden and number of vessels with obstructive disease.
The study shows that when stratified by 5 groups of coronary artery calcium scores, the presence of obstructive CAD was not associated with higher risk for CVD events and death than presence of nonobstructive CAD.
The main predictor of risk for CVD events and death appeared to be plaque burden, not stenosis per se.
Take-home message: patients with a comparable calcified atherosclerosis burden generally carry a similar risk for CVD events regardless of whether they have nonobstructive or obstructive CAD. The authors consider CTA as a very important tool to individualise the management of patients with high risk of major CVD events.