Inflammation has been the missing link in heart attack risk assessments
Not all patients with coronary plaques or high cholesterol will have a heart attack. In fact, a large number of heart attacks occur in patients without obstructive coronary artery disease (CAD). Often a patient’s first healthcare evaluation for heart disease is when they present to the hospital with chest pain.
ORFAN, late-breaking study using the Caristo technology Antoniades presented at AHA 2023 and published in 2024, showed patients without obstructive CAD were two times as likely to have heart attacks.(1) Out of the 40,000 patients tracked in the study, only 18% of cardiac events occurred in patients with obstructive CAD, showing inflammation was a key factor.
Newer CCTA AI technologies from vendors like Cleerly and Heartflow can already identify existing soft plaques, detail their composition and accurately quantify and track the plaques over time. However, plaque is stable unless it has the addition of inflammation, which makes them unstable and vulnerable to plaque rupture.
“Another important aspect of this is that by applying this kind of approach, you can identify coronary arteries which are inflamed before they even develop the plaque. Or you can find arteries that have minor plaques which are very inflamed, and they may cause a heart attack before you even see a large plaque,” Antoniades explained.
He said this new information could make a major impact in preventive cardiology going forward.
“This AI technology takes into account plaque inflammation, the risk factors of the patient, and it calculates the absolute risk for a fatal cardiac event over the next decade. And then from the moment you have that number, the guidelines tell you exactly what to do. This is exactly the beauty of this AI technology,” Antoniades said.
CT calcium scoring exams have been used for assessing coronary artery disease risk for several years, but it is falling out of favor with many cardiology experts in favor of soft plaque analysis. This is mainly due to calcified plaques being stable and not the primary cause for alarm. CCTA experts say the soft plaques that are not seen on calcium scoring scans are the real problem. And according to Antoniades, the addition of inflammation information will allow specialists to pinpoint which soft plaques to watch, and which patients need earlier or more intensive medication interventions.
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