Association of coronary artery calcium score with qualitatively and quantitatively assessed adverse plaque on coronary CT angiography in the SCOT-HEART trial

Maia Osborne-Grinter, Jacek Kwiecinski, Mhairi Doris, Priscilla Mcelhinney, Sebastien Cadet, Philip D. Adamson, Alastair J. Moss, Shirjel Alam, Amanda Hunter, Anoop S.V. Shah, Nicholas L. Mills, Tania Pawade, Chengjia Wang, Jonathan R. Weir-Mccall, Giles Roditi, Edwin J.R. Van Beek, Leslee J. Shaw, Edward D. Nicol, Daniel Berman, Piotr J. SlomkaDavid E. Newby, Marc R. Dweck, Damini Dey, Michelle C. Williams

Research output: Contribution to journalArticlepeer-review

25 Scopus citations


Aims: Coronary artery calcification is a marker of cardiovascular risk, but its association with qualitatively and quantitatively assessed plaque subtypes is unknown. Methods and results: In this post-hoc analysis, computed tomography (CT) images and 5-year clinical outcomes were assessed in SCOT-HEART trial participants. Agatston coronary artery calcium score (CACS) was measured on non-contrast CT and was stratified as zero (0 Agatston units, AU), minimal (1-9 AU), low (10-99 AU), moderate (100-399 AU), high (400-999 AU), and very high (≥1000 AU). Adverse plaques were investigated by qualitative (visual categorization of positive remodelling, low-attenuation plaque, spotty calcification, and napkin ring sign) and quantitative (calcified, non-calcified, low-attenuation, and total plaque burden; Autoplaque) assessments. Of 1769 patients, 36% had a zero, 9% minimal, 20% low, 17% moderate, 10% high, and 8% very high CACS. Amongst patients with a zero CACS, 14% had non-obstructive disease, 2% had obstructive disease, 2% had visually assessed adverse plaques, and 13% had low-attenuation plaque burden >4%. Non-calcified and low-attenuation plaque burden increased between patients with zero, minimal, and low CACS (P < 0.001), but there was no statistically significant difference between those with medium, high, and very high CACS. Myocardial infarction occurred in 41 patients, 10% of whom had zero CACS. CACS >1000 AU and low-attenuation plaque burden were the only predictors of myocardial infarction, independent of obstructive disease, and 10-year cardiovascular risk score. Conclusion: In patients with stable chest pain, zero CACS is associated with a good but not perfect prognosis, and CACS cannot rule out obstructive coronary artery disease, non-obstructive plaque, or adverse plaque phenotypes, including low-attenuation plaque.

Original languageEnglish
Pages (from-to)1210-1221
Number of pages12
JournalEuropean Heart Journal Cardiovascular Imaging
Issue number9
StatePublished - 1 Sep 2022
Externally publishedYes


  • atherosclerotic plaque
  • computed tomography
  • computed tomography coronary angiography
  • coronary calcium score
  • low-attenuation plaque


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