Coronary plaque burden and composition in an ESC guideline-selected outpatient CCTA cohort: age- and sex-specific percentile distributions

Coronary computed tomography angiography (CCTA) as first-line diagnostic tool for suspected coronary artery disease (CAD) offers detailed assessment of coronary plaque, yet data on non-calcified components remain limited. This study aims to analyze total coronary plaque burden as well as non-calcified plaque characteristics in an ESC-guideline-selected cohort and to establish age- and sex-specific percentile distributions and benchmark values for quantitative plaque assessment. All patients undergoing CCTA for a clinical indication at a German outpatient institution between July 2017 and June 2020 were included. Plaque analysis using validated semi-automated software was performed on all coronary arteries; plaque burden was measured with differentiation among total, calcified, non-calcified, and low-attenuation components. Of 5412 patients, coronary plaques were present in 67.1% of patients, with obstructive CAD in 29.3%. For example, the 50th, 75th, and 90th percentile values for total coronary plaque burden were 28.8 mm 3 , 130.2 mm 3 , and 302.0 mm 3 , respectively. Total plaque burden showed strong diagnostic performance for obstructive CAD, with optimal cut-off values of 68.45 mm 3 in males (sensitivity 0.89, specificity 0.74) and 21.18 mm 3 in females (sensitivity 0.93, specificity 0.77) showing the best discriminatory performance within the present cohort. Within this cohort, plaque burdens below 22.0 mm 3 in males and 12.4 mm 3 in females were associated with a false-negative rate below 5% for the presence of obstructive CAD. This study provides novel insights into the prevalence and distribution of coronary plaque burden in a large outpatient cohort undergoing CCTA according to current ESC guideline recommendations. The presented age- and sex-specific percentile distributions provide benchmark values for quantitative plaque assessment in a real-world CCTA population and may facilitate standardized reporting and future outcome-based investigations of coronary plaque burden and composition.