A recent retrospective study published in the International Journal of Cardiovascular Imaging highlights the clinical significance of CCTA coronary plaque assessment in patients with obstructive coronary artery disease (CAD). Clinicians often distinguish between focal and diffuse atherosclerosis to determine treatment efficacy. This study evaluated 597 lesions in 441 patients to identify how plaque composition and vulnerability features vary between these two phenotypes.

Comparing High-Risk Features in Focal and Diffuse Lesions

Researchers categorized plaques as diffuse if they exceeded 20 mm in length or covered at least 25% of the total vessel. Conversely, they defined shorter lesions as focal. Interestingly, the study found that focal lesions demonstrated a significantly higher prevalence of high-risk features. Specifically, CCTA coronary plaque assessment identified that spotty calcification, low-attenuation plaque, and positive remodeling were more common in focal disease. Additionally, focal lesions more frequently showed a plaque burden of 70% or greater.

In contrast, diffuse lesions exhibited higher overall calcification levels. However, clinical outcomes during follow-up revealed a different trend. Despite having fewer specific high-risk features per lesion, patients with diffuse disease experienced significantly higher rates of lesion-oriented myocardial infarction and revascularization. Therefore, while focal plaques may appear more vulnerable, the extensive nature of diffuse disease remains a major predictor of adverse events.

The Clinical Value of CCTA Coronary Plaque Assessment

Multivariate analysis confirmed that a plaque burden of 70% or more and CCTA-derived high-risk plaque (HRP) are independent predictors of cardiac outcomes. Consequently, radiologists and cardiologists should prioritize detailed plaque characterization beyond simple luminal stenosis. Furthermore, identifying these phenotypes helps in tailoring aggressive medical therapies or planning complex interventional procedures. Identifying the total plaque burden is essentially as important as spotting individual vulnerable spots.

Frequently Asked Questions

1. What are the specific CCTA markers for high-risk coronary plaque?

The primary markers include low-attenuation plaque, which indicates a lipid-rich necrotic core, and positive remodeling, where the vessel wall expands outward. Spotty calcification is another key indicator of potential plaque instability.

2. Why does diffuse disease lead to more revascularization if focal plaques are more \"vulnerable\"?

Diffuse disease represents a larger total area of atherosclerotic involvement. While focal plaques might have higher individual risk scores, the sheer extent of diffuse lesions increases the overall likelihood of developing ischemia or future clinical events over time.

3. Can CCTA accurately predict myocardial infarction risk?

Yes, CCTA is highly effective. As shown in this study, identifying a plaque burden of 70% or more combined with high-risk features serves as an independent predictor of future myocardial infarction and the need for revascularization.

Disclaimer: This content is for informational and educational purposes only. It does not constitute professional medical advice, diagnosis, or treatment. Refer to the latest local and national guidelines for clinical practice.

References

1. Durmaz ES et al. Non-invasive assessment of plaque characteristics in diffuse and focal coronary artery disease; plaque vulnerability and high-risk features. Int J Cardiovasc Imaging. 2026 Feb 09. doi: 10.1007/s10554-026-03638-4. PMID: 41656476.


2. Kovarnik T, et al. Coronary Atherosclerosis Phenotypes in Focal and Diffuse Disease. JACC Cardiovasc Interv. 2023 Jul 19. doi: 10.1016/j.jcin.2023.05.025.


3. Society of Cardiovascular Computed Tomography. Expert Consensus Document on Standards for Quantitative Assessments by CCTA. Journal of Cardiovascular Computed Tomography. 2024.