AI-Quantitative CT Coronary Plaque Features Associate With a Higher Relative Risk in Women: CONFIRM2 Registry

Background: Coronary plaque features are imaging biomarkers of cardiovascular risk, but less is known about sex-specific patterns in their prognostic value. This study aimed to define sex differences in the coronary atherosclerotic phenotypes assessed by artificial intelligence-based quantitative computed tomography (AI-QCT) and the associated risk of major adverse cardiovascular events (MACEs). Methods: Global multicenter registry including symptomatic patients with suspicion of coronary artery disease referred for coronary computed tomography angiography. AI-QCT analyzed 16 coronary artery disease features. The primary end point was MACE defined as death, myocardial infarction, late revascularization, cerebrovascular events, unstable angina, and congestive heart failure. Results: Among 3551 patients (mean age, 59±12 years; 49. 5% women), MACE occurred in 3. 2% of women and 6. 1% of men during an average follow-up of 4. 8±2. 2 years. The AI-QCT features total plaque volume, noncalcified plaque, calcified plaque, and percentage atheroma volume were significantly higher in men (P<0. 001), and high-risk plaques were more prevalent (9. 2% versus 2. 5%; P<0. 0001). Independent of age and cardiovascular risk factors, the AI-QCT-derived features of total plaque volume, noncalcified plaque, calcified plaque, and percentage atheroma volume conferred a higher relative risk of MACE in women than men. For every 50-mm3 increase in total plaque volume, relative risk increased by 17. 7% (95% CI, 1. 12-1. 24) in women versus 5. 3% (95% CI, 1. 03-1. 07) in men (P₈₍ₓ₄ₑ₀₂ₓ₈₎₍<0. 001) ; for noncalcified plaque, relative risk increased by 27. 1% (95% CI, 1. 17-1. 38) versus 11. 6% (95% CI, 1. 08-1. 15; P₈₍ₓ₄ₑ₀₂ₓ₈₎₍=0. 0015) ; and for calcified plaque, relative risk increased by 22. 9% (95% CI, 1. 14-1. 33) versus 5. 4% (95% CI, 1. 01-1. 10; P₈₍ₓ₄ₑ₀₂ₓ₈₎₍=0. 0012), respectively. Similarly, for percentage atheroma volume, the risk was higher in women. The findings remained unchanged when restricted to a secondary composite end point (death and myocardial infarction). Conclusions: The AI-QCT plaque features, total plaque volume, noncalcified plaque, calcified plaque, and percentage atheroma volume, conferred a higher relative MACE risk in women and may prompt more aggressive antiatherosclerotic therapy and reinforced preventive interventions. Registration: URL: https: //www. clinicaltrials. gov; Unique identifier: NCT04279496.