Key result
Coronary plaque burden is linked to ~4% higher 9-year adverse event risk per 1% increase.
Why the study?
Coronary plaque burden and myocardial ischaemia are recognized risk markers in suspected CAD, but their relative impact on cardiovascular outcomes over time remained incompletely understood.
Does quantitatively assessed coronary plaque burden and myocardial ischaemia predict the composite of death, non-fatal myocardial infarction, or unstable angina over time in patients with suspected coronary artery disease?
Cohort (n=1,385)
Does quantitatively assessed coronary plaque burden and myocardial ischaemia predict the composite of death, non-fatal myocardial infarction, or unstable angina over time in patients with suspected coronary artery disease?
In patients with suspected coronary artery disease, coronary plaque burden on CCTA consistently predicts adverse clinical outcomes up to 9 years, while PET-derived myocardial ischaemia primarily predicts short- and intermediate-term risk.
Plaque burden may refine long-term risk stratification in suspected CAD; extends evidence on ischaemia's time-limited prognostic role.
Background Coronary plaque burden and myocardial ischaemia are both recognised markers of risk in patients with suspected coronary artery disease (CAD). However, their relative impact on cardiovascular outcomes over time remains incompletely understood. Purpose To investigate the time-dependent prognostic value of quantitatively assessed coronary plaque burden and myocardial ischaemia in patients with suspected CAD. Methods We included patients with suspected CAD who underwent coronary computed tomography angiography (CCTA) and [15O]H2O positron emission tomography (PET) myocardial perfusion imaging. Plaque burden was measured on CCTA as percent atheroma volume (PAV) using AI-based analysis. Myocardial perfusion was assessed on PET by regional hyperaemic myocardial blood flow (hMBF). Multivariable Cox regression models including both PAV and hMBF were used to evaluate associations with a composite endpoint of death, non-fatal myocardial infarction, or unstable angina at 3, 6, and 9 years. Results Among 1,385 patients, mean age was 62 ± 9 years, 746 (54%) were men, median PAV was 7.9% (IQR: 2.7%–16.4%), and impaired regional perfusion was present in 678 (49.0%). During a median follow-up of 7.1 years, 185 patients (13%) experienced the composite endpoint. Higher PAV was independently associated with greater risk at all assessed time points, with HRs ranging from 1.036 to 1.047 per 1% increase (all p<0.001) (Figure 1). Lower hMBF was independently associated with adverse outcomes at 3 years (HR: 1.050; p=0.004) and 6 years (HR: 1.028; p=0.024), but not at 9 years (HR: 1.020; p=0.063), per 0.1 mL/min/g decrease (Figure 1). After excluding patients who underwent early revascularization, lower hMBF remained associated with outcomes throughout follow-up (Figure 2). Conclusions Coronary plaque burden and myocardial ischaemia provide independent prognostic information in suspected CAD. Plaque burden showed a consistent association with adverse outcomes over time, whereas ischaemia was mainly related to short- and intermediate-term risk, likely influenced by the effects of myocardial revascularization.Figure 1Figure 2
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Dahdal et al. (2026) conducted a cohort in Suspected coronary artery disease (CAD) (n=1,385). Coronary plaque burden (percent atheroma volume, PAV) and myocardial ischaemia (hyperaemic myocardial blood flow, hMBF) was evaluated on Composite of death, non-fatal myocardial infarction, or unstable angina (HR 1.036 to 1.047 per 1% PAV increase; HR 1.050 (3y), 1.028 (6y), 1.020 (9y) per 0.1 mL/min/g hMBF decrease, p=<0.001 for PAV; 0.004 (3y), 0.024 (6y), 0.063 (9y) for hMBF). Coronary plaque burden predicted adverse outcomes through 9 years (HR 1.036-1.047 per 1% increase, p<0.001), whereas lower hMBF predicted risk at 3 (HR 1.050) and 6 years (HR 1.028), not 9 years.
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