Key result
CAD-RADS 3/P0 links to ~16-fold higher major cardiovascular events risk, rivaling CAD-RADS 4-5 categories.
Why the study?
The prognostic value of plaque burden based on CACS and SIS categories over CAD-RADS in mild-to-moderate coronary disease required assessment.
Does CACS-based plaque burden (CACS-P score) compared to SIS-based plaque burden (SIS-P score) improve risk stratification for 5-point MACE over CAD-RADS categories in adults with very low-to-intermediate pre-test risk undergoing elective CCTA?
Cohort (n=1,818)
No
Does CACS-based plaque burden (CACS-P score) compared to SIS-based plaque burden (SIS-P score) improve risk stratification for 5-point MACE over CAD-RADS categories in adults with very low-to-intermediate pre-test risk undergoing elective CCTA?
Integrating CACS-based plaque burden scores into CAD-RADS 2.0 reveals substantial risk heterogeneity and refines prognostic stratification in patients with mild-to-moderate coronary stenosis, whereas SIS-based scoring provides limited additional value.
Answers are grounded in this paper and cite their sources.
CAD-RADS 3/P0 confers MACE risk comparable to CAD-RADS 4–5; leaves open whether CACS-P refines stratification beyond CAD-RADS 2.0.
Purpose To assess the prognostic value of plaque burden based on CACS and SIS categories over CAD-RADS. Methods In this retrospective, single-center study, 2850 adults who underwent elective CCTA between 2016 and 2020 were screened. A total of 1818 patients were enrolled based on very low-to-intermediate pre-test risk, good image quality (Likert score ≥4), and ≥3 years of follow-up. Clinical data were collected, and CAD-RADS 2.0 with CACS-based plaque burden (CACS-P score) and SIS-based plaque burden (SIS–P score) was quantified. Prediction of 5-point MACE composite outcome (late unplanned coronary revascularization, non-fatal myocardial infarction, hospitalization for heart failure, hospitalization for angina, all-cause mortality) and 2-point MACE composite outcome (non-fatal myocardial infarction and all-cause mortality) was evaluated using survival analysis and multivariable models. Results During a median available follow-up of 62 months, 178/1818 patients (9.8%) experienced a 5-point MACE and 96/1818 (5.3%) experienced myocardial infarction/death within the fixed 36-month analysis horizon. Both CAD-RADS severity and plaque burden scores were associated with adverse outcomes. Integration of the CACS-based P-score identified revealed heterogeneity in risk estimates within CAD-RADS categories. For the primary endpoint, CAD-RADS 3/P0 showed HR point estimates of similar magnitude to those observed in CAD-RADS 4–5/P0 and CAD-RADS 4–5/P3–P4 (HR 15.95 [95% CI:3.95–64.36], HR 16.21 [3.23–81.31], and HR 14.13 [5.70–35.01], respectively). For myocardial infarction/death, CAD-RADS 2–3/P0 showed HR point estimates of similar magnitude to those observed in CAD-RADS 4–5/P1–P2. Conversely, SIS–P provided limited additional within category risk stratification. Conclusions CACS-based P score may refine risk stratification in patients with mild-to-moderate stenosis.
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Palmisano et al. (2026) conducted a cohort in Mild-to-moderate coronary artery disease (n=1,818). CAD-RADS 2.0 with CACS-based plaque burden (CACS-P score) vs. SIS-based plaque burden (SIS-P score) and reference CAD-RADS categories was evaluated on 5-point MACE composite (late unplanned coronary revascularization, non-fatal myocardial infarction, hospitalization for heart failure, hospitalization for angina, all-cause mortality) (HR 15.95, 95% CI 3.95-64.36). CACS-based plaque burden refined CAD-RADS risk stratification, showing CAD-RADS 3/P0 had similar 5-point major cardiovascular events risk to CAD-RADS 4-5 categories, unlike SIS-P.
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