Prognostic Implications of Plaque Characteristics and Stenosis Severity in Patients With Coronary Artery Disease

Joo Myung Lee, Ki Hong Choi, Bon Kwon Koo, Jonghanne Park, Jihoon Kim, Doyeon Hwang, Tae Min Rhee, Hyung Yoon Kim, Hae Won Jung, Kyung Jin Kim, Kawase Yoshiaki, Eun Seok Shin, Joon Hyung Doh, Hyuk Jae Chang, Yun Kyeong Cho, Hyuck Jun Yoon, Chang Wook Nam, Seung Ho Hur, Jianan Wang, Shaoliang ChenShoichi Kuramitsu, Nobuhiro Tanaka, Hitoshi Matsuo, Takashi Akasaka

Research output: Contribution to journalArticlepeer-review

94 Citations (Scopus)


Background: Although the presence of ischemia is a key prognostic factor in patients with coronary artery disease, the presence of high-risk plaque characteristics (HRPC) is also associated with increased risk of cardiovascular events. Limited data exist regarding the prognostic implications of combined information on physiological stenosis severity assessed by fractional flow reserve (FFR) and plaque vulnerability by coronary computed tomography angiography (CTA)–defined HRPC. Objectives: The current study aimed to evaluate the: 1) association between physiological stenosis severity and coronary CTA-defined HRPC; and 2) prognostic implications of coronary CTA-defined HRPC according to physiological stenosis severity in patients with coronary artery disease. Methods: A total of 772 vessels (299 patients) evaluated by both coronary CTA and FFR were analyzed. The presence and number of HRPC (minimum lumen area <4 mm2, plaque burden ≥70%, low attenuating plaque, positive remodeling, napkin-ring sign, or spotty calcification) were assessed using coronary CTA images. The risk of vessel-oriented composite outcome (VOCO) (a composite of vessel-related ischemia-driven revascularization, vessel-related myocardial infarction, or cardiac death) at 5 years was compared according to the number of HRPC and FFR categories. Results: The proportion of lesions with ≥3 HRPC was significantly decreased according to the increase in FFR values (58.6%, 46.5%, 36.8%, 15.7%, and 3.5% for FFR ≤0.60, 0.61 to ≤0.70, 0.71 to ≤0.80, 0.81 to ≤0.90, and >0.90, respectively; overall p value <0.001). Both FFR and number of HRPC showed significant association with the estimated risk of VOCO (p = 0.008 and p = 0.023, respectively). In the FFR >0.80 group, lesions with ≥3 HRPC showed significantly higher risk of VOCO than those with <3 HRPC (15.0% vs. 4.3%; hazard ratio: 3.964; 95% confidence interval: 1.451 to 10.828; p = 0.007). However, there was no significant difference in the risk of VOCO according to HRPC in the FFR ≤0.80 group. By multivariable analysis, the presence of ≥3 HRPC was independently associated with the risk of VOCO in the FFR >0.80 group. Conclusions: Physiological stenosis severity and the number of HRPC were closely related, and both components had significant association with the risk of clinical events. However, the prognostic implication of HRPC was different according to FFR. Integration of both physiological stenosis severity and plaque vulnerability would provide better prognostic stratification of patients than either individual component alone, especially in patients with FFR >0.80.

Original languageEnglish
Pages (from-to)2413-2424
Number of pages12
JournalJournal of the American College of Cardiology
Issue number19
Publication statusPublished - 2019 May 21

Bibliographical note

Publisher Copyright:
© 2019 American College of Cardiology Foundation

All Science Journal Classification (ASJC) codes

  • Cardiology and Cardiovascular Medicine


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