RPS 303 - Coronary CT angiography, plaque burden and risk stratification: coronary plaque composition, adipose tissue and functional insights

Author Block: E. Ekkelenkamp¹, S. Dasselaar², J. Van Dijk¹, B. Vendel¹, J. Van Dalen¹, R. Vliegenthart³; ¹Zwolle/NL, ²Enschede/NL, ³Groningen/NL
Purpose: Computed tomography coronary angiography (CTCA) is a valuable tool to detect coronary plaques. Plaque composition may improve risk stratification. Our aim was to establish the value of coronary plaque composition quantification in addition to standard risk factors and CAD-RADS classification to predict occurrence of MACE.
Methods or Background: We identified 1700 patients who underwent CTCA between 2019 and 2021 for whom 2y follow-up was available. The 63 patients who experienced a MACE including all-cause death within 2 years were 1:1 propensity-score-matched to 63 patients without MACE based on CAD-RADS and standard risk factors.
In all 126 matched patients we measured plaque volumes using HU-based thresholds for non-calcified (≤ 30HU), fibrotic (31-350HU) and calcified plaques (>350HU) with commercial software (Advantage Workstation 3.2, GE Healthcare). Volume measurements were categorized into tertiles of low, middle or high plaque volume, for each plaque type. We compared plaque-volume tertiles in terms of MACE-occurrence using a Cox proportional hazards model, with lowest tertile as reference category.
Results or Findings: For the non-MACE and MACE groups, the median volumes of total (508 vs. 527mm3, p=0.36), non-calcified (51 vs. 58mm3, p=0.14), fibrotic (418 vs. 438mm3, p=0.32) and calcified plaque (44 vs. 38mm3, p=0.25) did not differ. Hazard ratios of total and non-calcified plaque tertiles for MACE ranged from 1.11 (p=0.77) to 1.66 (p=0.25), respectively. HR of the middle tertile for fibrotic plaque was 2.93 (p=0.04), and for the highest tertile HR 1.37 (p=0.73). Middle and high calcified plaque tertiles had HRs of 0.59 (p=0.12) and 0.60 (p=0.16), respectively.
Conclusion: We did not find evidence for benefit of CTCA-based volume measurements of coronary plaque components to identify patients at risk of MACE.
Limitations: Relatively small sample due to matched design based on MACE patient cohort.
Funding for this study: Not applicable.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:

Author Block: A-C. Stahl¹, K. Schulze¹, R. Bockelmann¹, F. Biavati¹, P. Maurovich-Horvat², K. F. Kofoed³, J. Dodd⁴, M. Dewey¹; ¹Berlin/DE, ²Budapest/HU, ³Copenhagen/DK, ⁴Dublin/IL
Purpose: To assess the association between socioeconomic status (SES), measured by income, and coronary artery plaque on computed tomography (CT) as well as major adverse cardiovascular events (MACE), defined as cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke in both randomisation groups of the Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) trial.
Methods or Background: This is a post-hoc analysis of the multicentre European DISCHARGE trial. Patients ≥30 years with stable chest pain referred for invasive coronary angiography (ICA) were randomised to ICA or CT. SES was determined by monthly net income, adjusted for country-specific price levels and normalised to the national median in the year of randomisation. Patients were categorised into low (≤1) and high (>1) SES groups. Cox survival analysis was used to assess associations between SES and MACE while a general linear model was used for associations with plaque volumes.
Results or Findings: Of 3561 patients, SES data were available for 2624 (1380 low SES). CT-based quantitative plaque analysis was performed in 1232 patients. After adjustment for age, sex, and cardiovascular risk factors, there was no significant difference in MACE between the low and high SES group (hazard ratio: 1.08, p=0.76). Coronary plaque volume was numerically higher in the low SES group, but differences were not statistically significant for total plaque volume (TPV, p=0.48), non-calcified plaque volume (p=0.66), or calcified plaque volume (p=0.36). SES remained not independently associated with TPV after adjustment (p=0.78).
Conclusion: SES was not associated with MACE or plaque volume suggesting that clinical risk factors outweigh socioeconomic influences in stable chest pain patients.
Limitations: SES was based on self-reported income, which may introduce misclassification. Therefore, residual confounding cannot be excluded.
Funding for this study: Funded by the European Union Seventh Framework Program and others; DISCHARGE ClinicalTrials.gov number: NCT02400229.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study was approved by ethics committee at Charité – Universitätsmedizin Berlin (EA1/294/13) as the coordinating centre, by the German Federal Office for Radiation Protection, and by local or national ethics committees.

Author Block: U. Anser, S. Azhe, L. Wen; Chengdu/CN
Purpose: To quantify epicardial adipose tissue (EAT) CT attenuation in children with Kawasaki disease (KD) and evaluate its associations with demographic and clinical factors, and the risk of adverse cardiovascular outcomes, aiming to establish EAT as a potential imaging biomarker of coronary risk.
Methods or Background: This retrospective study included 100 KD patients (mean age 8.2 ± 3.9 years) and 35 controls (mean age 8.4 ± 2.8 years) who underwent non-contrast cardiac CT between 2018 and 2024. EAT density was segmented manually (–190 to –30 HU) from the pulmonary bifurcation to the diaphragm. CT scans were performed in both acute and chronic stages of KD, reflecting the heterogeneous timing of imaging in clinical practice. Group comparisons were performed with the Mann–Whitney U test, correlations with Spearman’s rho, and predictors of EAT density with linear regression. Statistical significance was set at p<0.05.
Results or Findings: EAT CT attenuation was significantly lower in KD patients (–83.9 ± 2.7 HU) compared with controls (–86.3 ± 2.8 HU)(p<0.001). Within KD, lower EAT CT attenuation was associated with thrombosis (p=0.04) and calcification (p=0.03). A moderate positive correlation was observed between EAT CT attenuation and coronary Z-score (ρ=0.53, p<0.001). In regression analysis, both Z-score (β=0.27, 95% CI: 0.17–0.38, p<0.001) and age (β=0.15, 95% CI: 0.01–0.30, p=0.035) independently predicted higher EAT CT attenuation, whereas sex and BMI were not significant. The multivariable model explained 29% of the variance in EAT density (R²=0.293).
Conclusion: These findings suggest that EAT CT attenuation may serve as a potential imaging marker for coronary risk in KD, although larger studies are needed for validation.
Limitations: None
Funding for this study: Supported by the National Natural Science Foundation of China.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the Institutional Ethics Committee of West China Second University Hospital, Sichuan University. Given the retrospective design and anonymized use of clinical and imaging data, the requirement for informed consent was waived. All procedures were conducted in accordance with the Declaration of Helsinki (2013 revision).

Author Block: X. Chen¹, , Z. Li¹, X. Wan¹, T. Xu¹, X. Liu², Y. Liao², Y. Xu²; ¹Dongguan/CN, ²Guangzhou/CN
Purpose: To investigate pre-plaque epicardial adipose tissue (EAT), pericoronary fat attenuation index (FAI), and CT-derived fractional flow reserve (CT-FFR) on coronary computed tomography angiography (CCTA) as biomarkers for early cardiovascular risk in type 2 diabetes mellitus (T2DM) patients.
Methods or Background: We retrospectively collected 268 patients(from two hospitals, January 2022 – December 2024) with suspected coronary heart disease, normal coronary arteries on CCTA, newly diagnosed prediabetes(Pre-DM, n=132) or T2DM (n = 136) without prior treatment, and 142 healthy controls with normal CCTA and glucose profiles. Differences in EAT, FAI, and CT-FFR among the three groups were compared. Continuous variables were analyzed via Kruskal-Wallis H test with Bonferroni pairwise comparisons, and categorical variables via chi-square test.
Results or Findings: Kruskal-Wallis H test revealed significant intergroup differences in multiple parameters (EATV, EATV/BMI, FAI-Max，FAI-Mean, FAI-LAD, FAI-LCX; all p<0.05). Post-hoc analyses showed that most parameters significantly differed between the healthy and T2DM groups (EATV, EATV/BMI, FAI-Max，FAI-Mean, FAI-LAD, FAI-LCX; all p<0.05), while only FAI-Max significantly differed between healthy and Pre-DM groups (P=0.025). EATV was the sole parameter differing between Pre-DM and T2DM groups (P=0.03). CT-FFR, including all individual branches and the mean value, did not differ significantly among groups (all P>0.05).
Conclusion: In patients with early T2DM patients (including Pre-DM) but no plaques or functional myocardial ischemia (CT-FFR > 0.8), EATV and FAI (especially FAI-Max) were significantly higher than in healthy individuals. FAI-Max changed significantly at the Pre-DM stage, and EATV further increased with T2DM progression. CCTA-based Imaging features (such as EATV and FAI-Max) are expected to become non-invasive imaging biomarkers for assessing early cardiovascular risk in T2DM patients, providing important information for early clinical intervention.
Limitations: Single-center study with a smal l cohort
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The Ethics Committee granted a waiver of informed consent for this retrospective study.

Author Block: X. Zhao; Guiyang/CN
Purpose: To evaluate the image quality of coronary arteries with different body mass index (BMI) patients using a deep-learning reconstruction and to assess the feasibility of a contrast-agent dual-flow variable-rate injection protocol in coronary CT angiograph.
Methods or Background: In this prospective study, patients undergoing coronary CT angiography were randomly assigned to agroup A and group B. Each group was further stratified by BMI into three subgroups (<24.0 kg/m², 24.0–27.9 kg/m², ≥28.0 kg/m²), with 30 patients per subgroup. Group A received 40 mL of contrast at 5 mL/s followed by 10 mL of a 3:7 contrast/saline mixture at 3 mL/s (total contrast 43 mL). Group B received 50 mL of contrast at 5 mL/s. Both groups ended with a 30 mL saline flush; all images were reconstructed with a deep-learning algorithm. Image quality was scored subjectively and objectively (noise, CT attenuation, SNR, CNR). Radiation dose and immediate safety were also recorded.
Results or Findings: Group A used contrast dose 43 mL, while group B with 50 mL, representing a significant iodine reduction that remained adequate even in high-BMI patients. Subjective scores were consistently higher in group A across all BMI strata (p<0.05). Objective analysis showed higher SNR and CNR and lower noise in subgroups A1, A2, and A3 compared with B1, B2, and B3 (p<0.05), whereas CT attenuation values did not differ significantly. Effective radiation dose was lower in all A subgroups (p<0.05). Patient tolerance and safety profiles favored group A, with reduced injection burden.
Conclusion: Combining deep-learning reconstruction with post-dual-flow variable-rate injection protocol delivers high image quality while lowering both contrast volume and radiation dose across the full BMI spectrum, facilitating wider adoption of coronary CT angiography.
Limitations: First, small sample size.
Second, lack of pathological indicators.
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Ethics committee of Guiqian International Hospital

Author Block: C. Martini, F. L. Gurgoglione, E. Ridolo, A. A. Palumbo, G. Cicala, F. Nicoletta, C. Baldari, M. De Filippo, G. Niccoli; Parma/IT
Purpose: To evaluate whether patients with suspected chronic coronary syndromes (CCS) and allergic inflammatory diseases show differences in coronary CT angiography (CCTA)-derived atherosclerotic markers — including plaque extent, vulnerable phenotype, and pericoronary fat attenuation index (pFAI) — compared to non-allergic patients.
Methods or Background: Allergic inflammatory diseases are linked to higher risks of myocardial infarction and major adverse cardiovascular events. CCTA detects vulnerable plaques and inflammation markers, such as pFAI, enhancing risk stratification.
This study analyzed patients with suspected CCS undergoing clinically indicated CCTA at Parma University Hospital, stratified by allergic history. Plaque burden, vulnerable phenotype (≥2 high-risk features: positive remodeling, low-attenuation plaque, napkin-ring sign, spotty calcification), and pFAI were assessed at patient and lesion levels.
Results or Findings: A total of 289 patients (58 allergic, 20.1%) and 953 lesions were analyzed. CAD prevalence, extent, and severity were similar between groups. Allergic patients showed higher pFAI values (RCA: -65.72 vs -69.36, p=.012; LAD: -64.64 vs -68.81, p=.022; LCX: -61.36 vs -63.05, p=.024) and more vulnerable plaques (53 vs 186, p<.001), including more LAPs (51 vs 127, p<.001), spotty calcifications (31 vs 116, p=.015), and napkin-ring signs (27 vs 67, p<.001). Diabetes (OR 1.143, p<.001), allergy (OR 1.122, p=.003), and pFAI-RCA (OR 1.004, p=.014) predicted vulnerable plaque phenotype.
Conclusion: In suspected CCS, CAD prevalence and severity were similar regardless of allergy, but allergic patients showed greater pericoronary inflammation and more vulnerable plaques.
Limitations: - Single-center design
- Partial inclusion of allergic diseases
- Incomplete allergy characterization
- Lack of systemic inflammatory markers
- Exclusion of acute/prior CVD patients
- No clinical follow-up
Funding for this study: Nothing to declare
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Protocol number of approval by the Ethics Committee of the University Hospital of Parma (AOUPR): 150/2023/OSS/AOUPR SIRER ID 5860

Author Block: Y. Hou, H. Zhou, L. Weihua; Changsha/CN
Purpose: To investigate the diagnostic potential of left ventricular (LV) hemodynamic force (HDF) parameters to differentiate between acute myocarditis patients with heart failure with preserved ejection fraction (HFpEF) and those without heart failure (non-HF), while systematically comparing their performance against conventional LV strain parameters.
Methods or Background: We retrospectively analysis included 226 consecutive patients with acute myocarditis stratified by heart failure status: non-heart failure (non-HF) group and HF group (with preserved ejection fraction defined as LVEF≥50%). HDF parameters were calculated (I) as the root mean square of the apex-base directions during systole [HDF(Sys)] and diastole [HDF(Dia)]; (II) as the force ratios of the lateral-septal/apex-base directions during systole [R-Sys)], and diastole [R-(Dia)]. Additionally, LV global longitudinal strain (GLS), global circumferential strain (GCS) and global radial strain (GRS) were measured using a CMR feature tracking technique.
Results or Findings: Among 226 myocarditis patients, 53 had HF [HFpEF: 20 (8.8%); HFmrEF/HFrEF: 33 (14.6%)]. Compared to the non-HF group, HFpEF patients exhibited: I. Reduced LVEF (53.55±4.80 vs. 57.78±4.68, P=0.011); II. Impaired left ventricular strain parameters (LVGLS: −20.23±4.02 vs. −22.73±3.77, P=0.020); III. Increased R-Sys (19.49±7.17 vs. 12.90±3.89, P<0.001). R-Sys (AUC 0.836, cutoff 14.40%) distinguished HFpEF with 85.0% sensitivity and 76.3% specificity, outperforming LVEF (AUC 0.758, cutoff 51.98%) and GLS (AUC 0.675, cutoff 21.48%). R-Sys's discriminative power was significantly better than GLS (AUC 0.836 vs 0.675, p=0.043).
Conclusion: The LV hemodynamic force parameter (R-Sys) showed greater diagnostic accuracy than myocardial strain parameter (GLS) for detecting HFpEF in acute myocarditis patients.
Limitations: This study is a retrospective study with potential selection bias.
Funding for this study: This study was supported by the National Natural Science Foundation of China (82071984, 82071894, and 91959117)，the Science and Technology Innovation Program of Hunan Province (2020RC4007), and The Scientific Research Program of FuRong Laboratory 2024PT5110.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Medical Ethics Review Committee of Xiangya Hospital Central South University (2025061065)

Author Block: G. Cabrelle, A. Lupi, G. Ruperti, F. Mastro, M. Scordari, T. Melis, C. Zanon, G. Gerosa, A. Pepe; Padua/IT
Purpose: To evaluate whether coronary sinus (CS) size measured by CMR can discriminate between moderate and severe mitral regurgitation (MR).
Methods or Background: Retrospective, single-centre study from Padua University Hospital including patients referred for CMR from July 2024 to June 2025, affected by moderate-severe MR. Exclusion criteria: significant non-mitral valvular disease, history of cardiac surgery, major congenital heart disease, persistent left superior vena cava and ICDs. Cine SSFP sequences (width 6 mm, gap 0) sagittal to mitral anulus were analysed. CS maximum/minimum sagittal caliper and area were measured within 1 cm from CS ostium, together with indexed atrial and ventricular volumes, ejection fraction, mitral regurgitant volume and fraction, global longitudinal and circumferential strain.
Results or Findings: Thirty-four patients (66 ± 11 years, 17F). Moderate MR: 21 patients; severe MR: 13 patients. Ten patients underwent surgery. CS area showed a significant positive association with right indexed atrial volume (β = 3.15, p = 0.004). In multiple regression analysis, CS area was the strongest independent predictor of MR severity (β = 0.95, p < 0.0001), with adjusted R² = 0.75 for the model (p = 0.0002). A CS maximum caliper threshold of 14 mm and area of 0.97 cm² provided the best discriminatory performance.
Conclusion: CS maximum caliper and area emerge as predictors of MR severity and may serve as complementary parameters to improve diagnostic accuracy and pre-surgical stratification by CMR in patients with MR.
Limitations: Single center study
Sparse population
Funding for this study: None
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: