Coronary Plaque Characteristics Associated with Major Adverse Cardiovascular Events in Atherosclerotic Patients and Lesions

Background. The clinical value of high-risk coronary plaque characteristics (CPCs) to inform intensified medical therapy or revascularization of non-flow-limiting lesion remains uncertain.
Objectives. We performed a systematic review and meta-analysis to study the prognostic impact of CPCs on patient-level and lesion-level major cardiovascular adverse events (MACE).
Methods. Thirty studies (21 retrospective, 9 prospective) with 30,369 patients evaluating the association of CPC with MACE were included. CPCs included high plaque burden, low minimal lumen area, thin cap fibroatheroma, high lipid core burden index, low attenuation plaque, spotty calcification, napkin ring sign, or positive remodelling.
Results. CPCs were evaluated by intracoronary modalities in 9 studies (optical coherence tomography=4, intravascular ultrasound imaging=3, near-infrared spectroscopy intravascular ultrasound imaging=2) and by coronary computed tomography angiography (CCTA) in 21 studies. CPCs significantly predicted patient-level and lesion-level MACE in both unadjusted and adjusted analyses. For most CPCs, accuracy for MACE was modest to good at the patient-level and moderate to good at the lesion-level. Plaques with more than one CPC had the highest accuracy for lesion-level MACE (AUC 0.87). As the prevalence of CPCs among plaques was low, estimated positive predictive values for lesion-level MACE were modest. Results were mostly consistent across imaging modalities, clinical presentation and in studies with prevailing hard outcomes.
Conclusions. Characterization of CPCs identifies high-risk atherosclerotic plaques that place lesions and patients at risk for future MACE, albeit with modest sensitivity and positive predictive value (PROSPERO identifier:CRD42021251810).