From the Guidelines
A high plaque volume on a coronary computed tomography angiography (CCTA) is typically defined as a plaque burden of P3 or P4, indicating a severe amount of coronary plaque, according to the CAD-RADS 2.0 guidelines 1. This finding is concerning because it increases the risk of cardiovascular events, such as myocardial infarction, due to the potential for plaque rupture or erosion, triggering thrombosis 1. The management of high plaque volume typically requires aggressive medical management, including:
- High-intensity statin therapy, such as atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily
- Aspirin 81mg daily
- Lifestyle modifications, including a Mediterranean or DASH diet, regular exercise (150 minutes of moderate activity weekly), smoking cessation, and blood pressure control (target <130/80 mmHg)
- Evaluation for additional risk-reducing medications, such as PCSK9 inhibitors (evolocumab or alirocumab) if LDL remains elevated despite statins, or icosapent ethyl 2g twice daily if triglycerides are elevated
- Regular follow-up with a cardiologist, typically every 3-6 months initially, with lipid panel monitoring 1. It is essential to note that the presence of high-risk plaque features, such as spotty calcifications, low attenuation plaque, positive remodeling, and the "napkin ring sign", may also impact patient management and should be reported accordingly 1.
From the Research
Definition of High Plaque Volume on CCTA
- High plaque volume on Coronary Computed Tomography Angiography (CCTA) refers to a significant amount of atherosclerotic plaque present in the coronary arteries, which can increase the risk of cardiovascular events 2, 3.
- The characterization of coronary atherosclerosis by CCTA provides independent and incremental prognostic value above and beyond traditional measures of coronary artery disease (CAD) and is able to identify patients at risk of future events 2.
Features of High-Risk Plaque on CCTA
- High-risk plaque features on CCTA include spotty calcification, low attenuation plaque, positive remodelling, and the napkin ring sign 4.
- Quantitative plaque features, such as plaque burden, total-, noncalcific-, and fibrofatty plaque volume, are associated with increased risk of coronary events 2.
- The evaluation of coronary atherosclerosis, including the measurement of imaging risk scores (e.g., CT-adapted Leaman score), has been demonstrated as an independent long-term predictor of acute coronary events 2.
Clinical Implications of High Plaque Volume on CCTA
- A high plaque volume on CCTA is associated with an increased risk of major adverse cardiac events (MACE) and plaque progression 3, 5.
- The use of serial CCTA can identify plaque characteristics and plaque changes that are predictive of plaque progression and/or MACE at follow-up 3.
- CCTA can non-invasively characterize high-risk vulnerable coronary plaques and predict future acute coronary syndrome (ACS) events in patients with high-risk plaques 5.