Prognostic implications of serial coronary CTA–derived plaque burden in patients with coronary artery disease

Background The prognostic significance of plaque burden (PB) derived from coronary CTA is increasingly recognized, yet the incremental value of serial PB monitoring remains unclear. We evaluated the association between baseline PB and its long-term trends with MACCE in patients with coronary artery disease (CAD). Methods In a cohort of patients undergoing sequential CCTA evaluations (N=1,212), patients were stratified based on their initial examination results using the optimal plaque burden cut-off point (PB ≥ 15%). Among patients who underwent two sequential CCTA scans (N=1,204), PB status was divided into four groups: persistent low PB, low PB → high PB, high PB → low PB, and persistent high PB. The primary endpoint was MACCE, including unstable angina, myocardial infarction, heart failure, stroke, and cardiac death. Results Patients with PB ≥ 15% at initial coronary CT angiography demonstrated a significantly higher cumulative incidence of MACCE compared to those with PB < 15% (log-rank test P < 0.001). Compared with the persistently low PB group, the persistently high PB group had the highest risk of MACCE (aHR 3.4, 95% CI 2.13–5.29, P<0.001); The risk of MACCE also increased in the group transitioning from low to high PB (aHR 2.9, 95% CI 1.37–6.10, P=0.01); while the group transitioning from high-risk to low-risk PB (aHR 1.9, 95% CI 0.97–3.47, P=0.06) showed residual risk that was not statistically significant. Conclusions A plaque burden ≥15% can independently identify MACCE in CAD patients. Persistently high PB levels or PB progression can further guide long-term risk stratification. Dynamic monitoring of PB provides more clinically meaningful prognostic information.