Extent of cervicocephalic atherosclerosis is strongly associated with coronary burden in NSTEACS

Atherosclerosis is a systemic disease affecting multiple vascular beds. While prior studies have demonstrated associations between coronary and cervicocephalic atherosclerosis in cerebrovascular populations, the relationship in patients with non–ST-segment elevation acute coronary syndrome (NSTEACS) remains incompletely characterized. Moreover, whether cervicocephalic atherosclerosis extent (distribution across vascular beds) or severity (degree of focal stenosis) better reflects coronary atherosclerotic burden is unclear. This study aimed to evaluate the association between coronary atherosclerotic burden and cervicocephalic atherosclerosis characteristics in NSTEACS patients using simultaneous computed tomography angiography (CTA). In this single-center cross-sectional study, 186 patients with NSTEACS underwent simultaneous coronary and cervicocephalic CTA. Coronary atherosclerotic burden was quantified using coronary artery calcium score (CACS), CT-derived Gensini score, and vessel disease category. Cervicocephalic atherosclerosis was assessed by severity (maximal stenosis grade) and extent (bilateral involvement, combined extracranial/intracranial and anterior/posterior circulation disease, and number of stenotic segments ≥ 50%). Multivariable regression analyses evaluated associations between coronary atherosclerotic burden and cervicocephalic characteristics. Of 186 patients, 116 (62%) had cervicocephalic stenosis ≥ 50%. Patients with cervicocephalic atherosclerosis demonstrated higher coronary atherosclerotic burden, with elevated CACS [524 (435–613) vs. 93 (63–123), p < 0.001] and Gensini scores [53 (47–59) vs. 23 (20–25), p < 0.001], and greater multivessel disease prevalence ( p < 0.001). In multivariable analysis, extent-related parameters showed stronger associations with Gensini score than severity measures. Bilateral stenosis, combined extracranial/intracranial involvement, and the number of stenotic segments remained significantly associated after additional adjustment for maximal stenosis grade. Across Gensini quartiles, all extent parameters increased progressively (all p for trend < 0.001), whereas severity showed only a non-significant trend ( p = 0.068). Segment-specific analysis revealed significant associations for extracranial vertebral ( p = 0.020), intracranial carotid ( p < 0.001), and middle cerebral arteries ( p = 0.011). Symptomatic cerebral infarction was associated with higher CACS and Gensini scores (both p < 0.05). In NSTEACS patients, coronary atherosclerotic burden was more strongly associated with cervicocephalic atherosclerosis extent than severity. These findings support the concept of systemic atherosclerotic involvement across vascular beds and suggest that assessment of cervicocephalic disease extent may complement conventional stenosis-based evaluation by providing additional information on overall atherosclerotic burden.