Paradigms are bound to eventually change. After years blinded by stenosis degree, plaque volume has proven to be a better predictor of cardiovascular events and death. Thus, patients with similar degrees of atherosclerosis burden have a similar prognosis, regardless of their lesions being obstructive or not.
The aim of this work was to assess whether obstructive disease has an additional predictive value beyond its association with the total number of calcified atherosclerotic lesions evaluated by tomography.
This analysis, recently published in JACC, included 23,759 symptomatic patients diagnosed by angiography. Major cardiovascular events (infarction, stroke, and all-cause mortality) were stratified by atherosclerotic burden and number of affected vessels.
After a median follow-up of 4.3 years, 1054 patients experienced their first cardiovascular event. The event rate increased with both higher calcium scores and higher number of affected vessels. With a calcium score of 0, the event rate was 6.2 patients per 1000, while a >1000 score indicated a risk of 42.3 patients per 1000.
Having 1 affected vessel provided a similar risk of events than a calcium score of 0 (6.1 patients per 1000), while having all 3 vessels affected was not as severe as a calcium score >1000 (34.7 patients per 1000).
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After stratifying patients into 5 groups according to their calcium score (0, 1-99, 100-399, 400-1000, and >1000), the presence of obstructive disease was not associated with a higher risk when compared with patients without obstructive disease.
Conclusion
Plaque volume, and not stenosis per se, is the best predictor for cardiovascular events and death.
Original title: Impact of Plaque Burden Versus Stenosis on Ischemic Events in Patients With Coronary Atherosclerosis.
Reference: Martin Bødtker Mortensen et al. J Am Coll Cardiol 2020;76:2803–13 https://doi.org/10.1016/j.jacc.2020.10.021.
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