Perspective:

Prior literature by this group and others has demonstrated that specific plaque characteristics on CTA may be associated with an increased risk of adverse events including ACS. This study expands on these prior studies by following patients over a longer period of time and by evaluating the significance of plaque progression on CTA. It must be acknowledged that this is a retrospective cohort study, and as such, it is susceptible to selection bias. Nevertheless, the results are intriguing. At present, we have many tests that can accurately identify patients with coronary artery disease, but we have significant difficulty determining patients at risk of coronary events. This study highlights the limited associations between cardiovascular risk factors or luminal stenosis and the risk of adverse events, and suggests that findings such as plaque progression or high-risk plaque could help us better identify patients at risk. For now, it may be reasonable to report these findings when they are observed, given their potential association with risk. Prospective studies are needed, however, to validate these findings, and to determine whether these results change management or alter outcomes.