Perspective:

Several multicenter studies have demonstrated that both nonobstructive and obstructive CAD identified by CTA are associated with adverse events, with most studies using all-cause mortality as the primary endpoint. This present single-center study is consistent with these prior studies, although it examines more robust endpoints that include cardiac-specific death, MI, and late revascularization. A limitation of the present study is that approximately two thirds of events represented late revascularization, although in analyses limited to death or MI, both CACS and CTA findings remained associated with these hard adverse events. Interestingly, when the authors examined the composition of the most stenotic lesion, patients with noncalcified or mixed plaque had a significantly increased risk of MACE, as compared to calcified plaque. These findings underscore the potential disadvantage of CACS, as it examines only calcified plaque components, and prompt the need for further research examining the relationship between plaque composition and the risk of cardiac events.