Association between CCTA-identified high-risk plaques and preventive therapy modification

Background Vulnerable plaques are associated with an increased risk of cardiovascular events. Coronary Computed Tomography Angiography (CCTA) is emerging as a non-invasive imaging modality for detecting high-risk plaque (HRP) features, increasingly informing clinical decision-making and guiding preventive strategies. This study aimed to investigate the association between HRP features detected on CCTA and subsequent modifications in the prescription of preventive therapies. Methods In a cohort of patients who underwent CCTA to rule-out obstructive coronary artery disease (CAD), patients with HRP features (characterized by low-attenuation plaque, positive remodelling, spotty calcifications and the napkin-ring sign), were matched 1:1 via propensity score matching to patients without these features. Matching was based on age, sex, CAD-RADS score, cardiovascular risk factors and use of statins and acetylsalicylic acid prior to CCTA at baseline. Medication use was recorded at baseline and 4 weeks post-CCTA. Statistical comparisons were performed using McNemar’s tests. Results Out of 2714 patients with CAD, 440 (16%) exhibited at least one HRP feature. A total of 436 matched pairs of patients with and without HRP features were compared. Baseline characteristics were similar between groups (mean age 61 ± 9 vs. 60 ± 9 years; male 70% vs 69%). Although baseline statin use was comparable (32% vs. 35%), statin use at 4 weeks was significantly higher in the HRP group (69% vs. 63%, p = 0.036). Similarly, acetylsalicylic acid use increased from 32% vs. 33% at baseline to 60% vs. 53% at 4 weeks (p = 0.010). Analysis of therapy change patterns revealed that among patients with HRP features 37% initiated statin therapy, 32% continued, 0.2% discontinued, and 31% remained off statin therapy. In contrast, patients without HRP had rates of 29%, 34%, 0.7%, and 36%, respectively. For acetylsalicylic acid changes, 31% of patients with HRP started therapy vs. 24% of patients without HRP, with 29% vs. 28% continuing medication, 3% vs. 5% stopping, and 38% vs. 43% continuing no therapy. Conclusion Detection of HRP features on CCTA is associated with a significant increase in the initiation of statins and acetylsalicylic acid, suggesting that CCTA can promote more aggressive secondary prevention strategies. Nonetheless, despite the established prognostic significance of vulnerable plaques, the overall initiation rate of treatment remains suboptimal. Increased awareness and stricter adherence to guideline-based risk management strategies are essential to enhance preventive care in this vulnerable population.