Low-attenuation Coronary Plaque Volume and Cardiovascular Events in Patients with Distinct Metabolic Phenotypes

BackgroundThis study aimed to investigate the association between diabetes mellitus (DM), high-risk coronary plaque burden, and risk of cardiovascular outcomes across metabolic phenotypes in patients with suspected coronary artery disease (CAD) who underwent coronary computed tomography angiography (CCTA). MethodsWe included 530 patients who underwent CCTA. Metabolic syndrome (MetS) was defined as the presence of a visceral adipose tissue area [≥] 100 cm2 in patients with DM (n = 58), or two or more MetS components excluding DM (n = 114). Remaining patients were categorized into non-MetS patients with DM (n = 52) and non-MetS patients without DM (n = 306). CCTA-based high-risk plaque was defined as low-attenuation plaque (LAP) volume > 4 %. Primary endpoint was presence of a major cardiovascular event (MACE), which was defined as a composite of cardiovascular death, acute coronary syndrome, and coronary revascularization. ResultsIncidence of MACE was highest in the non-MetS with DM group, followed hierarchically by the MetS with DM, MetS without DM, and non-MetS without DM groups. In the multivariable Cox hazard model analysis, DM as a predictor was associated with MACE independent of LAP volume > 4 % (hazard ratio, 2.68; 95% confidence interval, 1.16-6.18; p = 0.02), although MetS did not remain an independent predictor. LAP volume > 4 % remained a predictor of MACE independent of each metabolic phenotype or DM. ConclusionsThis study demonstrated that DM, rather than MetS, is a predictor of coronary events independent of high-risk plaque volume in patients who underwent CCTA. Clinical PerspectiveO_LIWhat Is New? O_LIThis study investigated the association between diabetes mellitus (DM), high-risk coronary plaque burden, and major adverse cardiovascular events (MACE) across metabolic phenotypes stratified by the presence or absence of metabolic syndrome (MetS) and DM in patients with suspected coronary artery disease (CAD) who underwent coronary computed tomography angiography (CCTA). C_LIO_LIAmong the four metabolic phenotypes, incidence of MACE was highest in the non-MetS with DM group, followed hierarchically by the MetS with DM, MetS without DM, and non-MetS without DM groups. Low-attenuation coronary plaque (LAP) volume > 4% was a robust predictor of MACE among the metabolic phenotypes. Furthermore, DM, independent of LAP volume > 4%, was a predictor of MACE, while MetS did not show a significant predictive value. C_LI C_LIO_LIWhat Are the Clinical Implications? O_LIOur results demonstrate that individuals with DM alone have a significantly higher risk of developing cardiovascular events than those with MetS, indicating that DM is an independent predictor of cardiovascular events irrespective of the presence of obstructive CAD or LAP volume greater than 4%. C_LI C_LI