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CTCA High-risk Plaque Features — EECC MCQ

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HardCardiac ImagingCTCA High-risk Plaque FeaturesEECC

A 55-year-old man with chest pain and intermediate PTP undergoes CTCA. The report describes a 60% stenosis with a low-attenuation plaque containing spotty calcification and positive remodelling. What is the significance of these plaque characteristics?

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Correct answer: D — These are high-risk (vulnerable) plaque features associated with increased risk of ACS — low attenuation indicates a lipid-rich necrotic core, spotty calcification suggests inflammation, and positive remodelling is an early response to plaque growth

CTCA provides not only anatomical stenosis severity but also plaque characterisation, which has emerged as a powerful prognostic tool. High-risk (vulnerable) plaque features include: (1) low-attenuation plaque (<30 HU — lipid-rich necrotic core); (2) spotty calcification (small calcium deposits within the plaque, indicating active inflammation/plaque instability, distinct from dense calcification which is more stable); (3) positive (outward) remodelling (remodelling index >1.1 — the vessel wall expands to accommodate the plaque before luminal encroachment occurs); (4) napkin-ring sign (ring of high attenuation surrounding a low-attenuation core). These features are independently associated with future ACS events and may identify patients who benefit from intensified medical therapy regardless of stenosis severity.

Reference: ESC (2024): CCS Guidelines; SCOT-HEART Trial