What is the clinical evidence from this study?

Study design: Observational. Population: Coronary artery disease (n=94). Intervention: Coronary artery calcium (CAC) density. Primary outcome: IVUS-confirmed attenuated plaques (OR 0.994, 95% CI 0.990-0.997, p=0.0002).

What does this research mean for the field?

Lower CAC density independently predicts IVUS-confirmed attenuated plaques, with a sensitivity of 81.8% and specificity of 66.1% at a cutoff of 461.50 HU. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

The study aims to evaluate the relationship between coronary artery calcium metrics and the identification of unstable plaques in patients with coronary artery disease.

February 2, 2026Open Access

Association of Attenuated Plaques Detected by Intravascular Ultrasound With Plaque Calcification Assessed by Computed Tomography Angiography

Key Result

Lower coronary artery calcium density derived from computed tomography angiography independently predicted the presence of IVUS-confirmed attenuated plaques (OR 0.994).

Key Points

The study aims to evaluate the relationship between coronary artery calcium metrics and the identification of unstable plaques in patients with coronary artery disease.
Retrospective analysis of patients with coronary artery disease undergoing both CCTA and IVUS.
Used CCTA to measure plaque volume, density, and composition.
Characterized plaques as attenuated or non-attenuated via IVUS.
Very strong correlation between calcium volume and total plaque volume (rs = 0.953, p < 0.0001).
Attenuated plaques had significantly lower calcium density, volume, and percentage compared to non-attenuated plaques.
Lower CAC density was identified as an independent predictor of IVUS-confirmed attenuated plaques (odds ratio = 0.994, p = 0.0002).
CCTA-derived CAC density showed an AUROC of 0.735 in diagnosing attenuated plaques.

Study Design

Type

Observational (n=94)

Multicenter

Structured PICO

Does lower CCTA-derived coronary artery calcium (CAC) density predict IVUS-confirmed attenuated plaques in patients with coronary artery disease?

Population

94 patients with coronary artery disease (CAD) with 150 coronary plaques, median age 63.0, 78.7% male, based in China. Key inclusion: underwent both CCTA and IVUS between January 2023 and December 2024. Key exclusion: CCTA-IVUS interval >4 weeks, suboptimal CCTA, prior revascularization of target lesions.

Intervention

Coronary computed tomography angiography (CCTA)-derived coronary artery calcium (CAC) density assessment

Comparator

Intravascular ultrasound (IVUS)-defined non-attenuated plaques

Outcome

Presence of IVUS-confirmed attenuated plaquessurrogate

CCTA-derived CAC density can serve as a noninvasive marker of plaque stability, with lower density independently predicting vulnerable, IVUS-confirmed attenuated plaques.

Main Result

Effect estimate: OR 0.994 (95% CI 0.990-0.997)

p-value: p=0.0002

Limitations

Single-center retrospective study with a relatively small cohort
Analyses were performed at the lesion level without accounting for intra-patient clustering
Reproducibility of attenuated plaque assessment was not evaluated
Calcification morphology such as spotty or microcalcification was not analyzed

Abstract

Background: Coronary artery calcium (CAC) reflects the overall atherosclerotic burden. The CAC density is inversely associated with plaque vulnerability. Intravascular ultrasound (IVUS)-defined attenuated plaques represent unstable lesions, which are linked to adverse clinical outcomes. Meanwhile, the determination as to whether coronary computed tomography angiography (CCTA)-derived CAC metrics can serve as noninvasive markers of attenuated plaques remains uncertain. Methods: This retrospective study included coronary artery disease (CAD) patients who underwent both CCTA and IVUS between January 2023 and December 2024 at our medical center. CCTA was used to quantify plaque volume, density, and composition (lipid, fiber, and calcium), while IVUS was employed to characterize the plaques as attenuated and non-attenuated. Results: Among 94 patients with 150 coronary plaques, calcium volume showed a very strong correlation with total plaque volume (rs = 0.953, p < 0.0001). Meanwhile, attenuated plaques exhibited significantly lower calcium density (321.00 vs. 499.00 Hounsfield units (HU); p = 0.0004), calcium volume (55.20 vs. 168.10 mm3; p = 0.003), and calcium percentage (33.30% vs. 55.40%; p = 0.015) compared with the non-attenuated plaques. Multivariate logistic regression analysis identified lower CAC density as the only independent predictor of IVUS-confirmed attenuated plaques (odds ratio = 0.994, 95% confidence interval (CI): 0.990–0.997; p = 0.0002). The area under the receiver operating characteristic (AUROC) curve for CAC density in diagnosing attenuated plaques was 0.735 (95% CI: 0.603–0.868; p = 0.0004). At a cutoff of 461.50 HU, the sensitivity and specificity were 81.8% and 66.1%, respectively. Conclusion: CCTA-derived CAC volume reflects the atherosclerosis (AS) burden, while lower CAC density independently predicts IVUS-confirmed attenuated plaques. A higher CAC density was associated with plaque stability, suggesting that the CCTA-derived CAC density may serve as a noninvasive marker of plaque stability, aiding in the assessment of plaque vulnerability and risk stratification.

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