Identifying coronary lesions at risk for near-term acute myocardial infarction (AMI) remains a key challenge in cardiovascular imaging. A study presented at ACC.26 evaluated whether plaque characteristics on coronary computed tomographic angiography (CCTA) are associated with the timing of MI events.

This retrospective analysis included 227 patients who underwent CCTA and subsequently developed AMI within 1 month to 4 years. Based on time to event, 102 patients were categorized as short-term (<1 year) and 125 as long-term (1-4 years). Culprit lesions were identified using invasive coronary angiography and matched with prior CCTA findings. Imaging parameters included stenosis severity, plaque composition, high-risk plaque features, perivascular fat attenuation index (FAI), and CT-derived fractional flow reserve (CT-FFR).

After adjustment for CT-FFR, FAI, stenosis severity, and clinical variables, total plaque burden (odds ratio [OR] 1.02; 95% confidence interval [CI], 1.01 to 1.04) and fibrotic plaque burden (OR 1.06; 95% CI, 1.01 to 1.10) remained independently associated with short-term MI at the vessel level. At the lesion level, total plaque (OR 1.02; 95% CI, 1.01 to 1.03), non-calcified plaque (OR 1.02; 95% CI, 1.01 to 1.04), and fibrotic plaque burden (OR 1.04; 95% CI, 1.01 to 1.09) showed significant associations after further adjustment for high-risk plaque features.

These findings indicate that greater plaque burden, particularly fibrotic and non-calcified components, is associated with higher short-term MI risk, supporting the role of CCTA-derived plaque characterization in risk stratification.