title: The high-risk criteria low-attenuation plaque <60 HU and the napkin-ring sign are the most powerful predictors of MACE: a long-term follow-up study.
abstract: OBJECTIVE
  To assess the prognostic value of coronary CT angiography (CTA) for prediction of major adverse cardiac events (MACE) over a long-term follow-up period.
  
  
  RESULTS
  A total of 1469 low-to-intermediate-risk patients (65.9 years; 44.2% females) were included in our prospective cohort study. CTA was evaluated for (i) stenosis severity (minimal <10%; mild <50%; moderate 50-70%; severe >70%), (ii) plaque types (calcified, mixed dominantly calcified, mixed dominantly non-calcified, non-calcified), and (iii) high-risk plaque criteria [low-attenuation plaque (LAP) quantified by HU, napkin-ring (NR) sign, spotty calcification <3 mm, and remodelling index (RI)]. Over a follow-up of mean 7.8 years, MACE rate was 41 (2.8%) and 0% in patients with negative CTA. MACE rate increased along with stenosis severity by CTA (from 1.3 to 7.8%) (P < 0.001) and was higher in T3/T4 plaques than in T2/T1 (7.8 vs. 1.9%; P < 0.0001). LAP density was lower (35.2 HU ± 32 vs. 108.8 HU ± 53) (P < 0.001) and both NR-sign prevalence with n = 26 (63.4%) vs. n = 40 (28%) and LAP <30, <60, and <90 HU prevalence with 46.3-78% vs. 2.4-7% were higher in the MACE group (P < 0.001). On univariate and unadjusted multivariable proportional Hazards model, LAP <60 HU and NR were the strongest MACE predictors (HR 4.96; 95% CI: 2.0-12.2 and HR 3.85; 95% CI: 1.7-8.6) (P < 0.0001), while spotty calcification (HR 2.2; 95% CI: 1.1-4.3, P < 0.001), stenosis severity, and plaque type (HR 1.5; 95% CI: 1.1-2.3 and HR 1.7; 95% CI: 1.1-2.6) (P < 0.001) were less powerful. After adjusting for risk factors, CTA stenosis severity, and plaque type, LAP <60 HU and the NR sign remained significant (P < 0.001), while the effect of NR sign was even enhancing. HRP criteria were independent predictors from other risk factors.
  
  
  CONCLUSIONS
  Prognosis is excellent over a long-term period if CTA is negative and worsening with an increasing non-calcifying plaque component. LAP <60 HU and NR sign are the most powerful MACE predictors.
authors: Department of Radiology, Innsbruck Medical University,Anichstr. 35, A-6020 Innsbruck, Austria.
authors: Gudrun
authors: G
authors: Feuchtner
authors: Department of Radiology, Innsbruck Medical University,Anichstr. 35, A-6020 Innsbruck, Austria.
authors: Johannes
authors: J
authors: Kerber
authors: Department of Radiology, Innsbruck Medical University,Anichstr. 35, A-6020 Innsbruck, Austria.
authors: Philipp
authors: P
authors: Burghard
authors: Department of Internal Medicine III-Cardiology, Innsbruck Medical University, Innsbruck, Austria.
authors: Wolfgang
authors: W
authors: Dichtl
authors: Department of Internal Medicine III-Cardiology, Innsbruck Medical University, Innsbruck, Austria.
authors: Guy
authors: G
authors: Friedrich
authors: Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria.
authors: Nikolaos
authors: N
authors: Bonaros
authors: Department of Radiology, Innsbruck Medical University, Anichstr. 35, A-6020 Innsbruck, Austria.|Department of Internal Medicine III-Cardiology, Innsbruck Medical University, Innsbruck, Austria.
authors: Fabian
authors: F
authors: Plank
mesh_terms: D000368:Aged; D017225:Atherectomy, Coronary / Q000379:methods; D015331:Cohort Studies; D000072226:Computed Tomography Angiography / Q000379:methods*; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000473:pathology / Q000628:therapy; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007091:Image Processing, Computer-Assisted; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000000981:diagnostic imaging* / Q000503:physiopathology; D058226:Plaque, Atherosclerotic / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012372:ROC Curve; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
keywords: atherosclerosis; computed tomography; coronary artery disease; high-risk plaque; major adverse cardiac events (MACE)