Key result
High-risk CAD-RADS 2.0 classification is linked to ~2.9-fold higher MACE risk in stable chest pain.
Why the study?
The prognostic value of integrating plaque burden into CAD-RADS 2.0 beyond stenosis severity alone in patients with stable chest pain undergoing CCTA had not been fully evaluated.
Does the high-risk CAD-RADS 2.0 category integrating coronary plaque burden provide independent and incremental prognostic value for predicting major adverse cardiovascular events beyond stenosis severity in patients with stable chest pain undergoing CCTA?
Cohort (n=563)
Readers were blinded to subsequent clinical outcomes; events adjudicated by a clinician blinded to baseline CCTA findings and CAD-RADS classification
No
Does the high-risk CAD-RADS 2.0 category integrating coronary plaque burden provide independent and incremental prognostic value for predicting major adverse cardiovascular events beyond stenosis severity in patients with stable chest pain undergoing CCTA?
Integrating coronary plaque burden via the Segment Involvement Score into CAD-RADS 2.0 identifies high-risk stable chest pain patients—especially those with non-obstructive stenosis—who are at significantly increased risk for MACEs beyond luminal stenosis severity alone.
Answers are grounded in this paper and cite their sources.
May refine risk stratification beyond stenosis in stable chest pain; extends CAD-RADS 2.0 but remains hypothesis-generating.
Introduction: Coronary computed tomography angiography (CCTA) is a noninvasive test for suspected coronary artery disease (CAD), but the prognostic value of integrating plaque burden into CAD-RADS 2.0 has not been fully evaluated. We aimed to assess whether the high-risk CAD-RADS 2.0 category, which combines stenosis severity and segment involvement score (SIS), provides prognostic information beyond stenosis severity in patients with stable chest pain. Methods: We retrospectively included 563 consecutive patients with stable chest pain who underwent CCTA between 2017 and 2022. CAD-RADS 1.0 categories and CAD-RADS 2.0 plaque burden grades were assigned by experienced radiologists. High-risk CAD-RADS 2.0 was defined as CAD-RADS ≥ 3 or any CAD-RADS with P-SIS ≥ 3. The primary endpoint was major adverse cardiovascular events (MACEs). Given the limited number of events, multivariable analysis was restricted to clinically justified parsimonious Cox proportional hazards models. A model including age, sex, and significant stenosis was compared with a model including age, sex, and the high-risk CAD-RADS 2.0 category. A formally nested extended model additionally included severe-to-extensive plaque burden. Results: Over a median follow-up of 51.2 months, 41 patients (7.3%) experienced MACEs. Among patients with non-obstructive CAD (CAD-RADS 1–2), 29 of 477 (6.1%) experienced MACEs, and 85.4% of these events occurred in patients with severe or extensive plaque burden (P3–P4). After adjustment for age and sex, significant stenosis was not associated with MACEs, whereas the high-risk CAD-RADS 2.0 category was independently associated with MACEs (HR 2.88, 95% CI 1.07–7.75; p = 0.036). Addition of plaque burden to a model including age, sex, and significant stenosis increased the Harrell C-index from 0.760 to 0.772 and significantly improved model fit (likelihood-ratio χ2 = 5.41; p = 0.020). In the extended model, plaque burden remained independently associated with MACEs (HR 2.81, 95% CI 1.10–7.19; p = 0.031). Conclusions: In patients with stable chest pain undergoing CCTA, the high-risk CAD-RADS 2.0 category was independently associated with MACEs. Formal incremental analyses demonstrated that plaque burden provided prognostic information beyond age, sex, and significant stenosis. These findings support the prognostic relevance of integrating plaque burden into CCTA-based risk classification but require confirmation in larger prospective and externally validated cohorts.
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Ezponda et al. (2026) conducted a cohort in Stable chest pain and suspected coronary artery disease (CAD) (n=563). High-risk CAD-RADS 2.0 category (CAD-RADS ≥ 3 or any CAD-RADS with plaque burden P-SIS ≥ 3) vs. Non-high-risk CAD-RADS 2.0 category (or conventional stenosis-based assessment via CAD-RADS 1.0) was evaluated on Major adverse cardiovascular events (MACEs), defined as hospitalization for heart failure, acute myocardial infarction, unstable angina, stroke, or cardiovascular death (HR 2.88, 95% CI 1.07–7.75, p=0.036). High-risk CAD-RADS 2.0 classification integrating plaque burden was independently associated with MACEs (HR 2.88, 95% CI 1.07–7.75; p=0.036) in patients with stable chest pain undergoing CCTA.
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