Influence of plaque characteristics by coronary computed tomography angiography on lesion-specific ischemia: a systematic review and meta-analysis.

objectivesTo evaluate the association between plaque characteristics and burden by coronary computed tomography angiography (CCTA) and ischemia determined by invasively measured fractional flow reserve (FFR), and whether the addition of plaque characteristics improves ischemia discrimination beyond coronary stenosis alone.

methodsA systematic literature review and meta-analysis of studies from PubMed, EMBASE, and the Cochrane Library databases, published between January 2005 and October 2024 were conducted to assess the relationship between quantitative and qualitative coronary plaque characteristics and invasive FFR. Pooled analyses were performed using weighted mean difference for plaque volumes with 95% confidence intervals and odds ratios for qualitative plaque findings.

resultsA total of 29 studies involving 4416 patients (mean age 63 ± 9 years and 71% male) with predominantly stable coronary artery disease were included. Data on 3923 lesions and 3520 vessels were pooled. Total plaque, non-calcified plaque, and percent aggregate plaque volumes, as well as percent plaque burden, were inversely associated with FFR at both per-lesion and per-vessel levels (all, p-values < 0.05). The presence of high-risk plaque characteristics, including low-attenuation plaque, napkin-ring sign, and spotty calcification, were more frequently observed in lesions and vessels with FFR ≤ 0.80 (all, p-values < 0.05). Among plaque volumes, the percent aggregate plaque volume consistently improved ischemia discrimination independently of stenosis.

conclusionCCTA-derived quantification of plaque volumes and identification of high-risk plaque characteristics are associated with ischemia and significantly enhance discrimination of ischemia-causing lesions independently of coronary stenosis severity. KEY POINTS: Question Plaque characteristics have been suggested as the missing link between coronary artery stenosis severity and ischemia. Findings High-risk plaque characteristics and larger coronary plaque volumes are associated with ischemia (FFR ≤ 0.80). Clinical relevance The addition of CCTA-derived plaque assessment improved the discrimination of ischemia compared with stenosis evaluation alone. Combining coronary stenosis and plaque assessment may improve the non-invasive assessment of patients with coronary artery disease and gatekeeping to the catheterization laboratory.