LAUSR

This editorial refers to ‘Improved 5-year prediction of all-cause mortality by coronary CT angiography applying the CONFIRM score’, by S. Deseive et al. doi: 10.1093/ehjci/jew195. Coronary computed tomography angiography (CTA) underwent a remarkable evolution during the past 10 years. From a robust rule out test and gate keeper of invasive coronary angiography—because of its excellent negative predictive value and high sensitivity to identify luminal obstruction—computed tomography (CT) became a comprehensive imaging test that is able to depict coronary atherosclerosis in a more holistic way.2 The ability of coronary CTA to visualize the entire coronary tree and assess individual plaque types opens new avenues in cardiovascular risk assessment. At the dawn of precision medicine, it is important to comprehend the rich information provided by CT to predict adverse cardiac events and tailor medical therapies. The notion to assess high-risk plaque features to improve risk stratification has initiated several clinical studies. Plaque features, such a positive remodelling, low CT attenuation, napkin-ring sign, and spotty calcification, proved to identify patients with higher risk to suffer myocardial infarction.3–5 However, the predictive value of high-risk plaque features has been questioned based on the results of the PROPSEPCT (Providing Regional Observations to Study Predictors of Events in the Coronary Tree) study, which demonstrated a very low event rate associated with each individual high-risk lesion as assessed by intravascular ultrasound.6 Furthermore, none of the CT studies considered total plaque burden as a potential confounder, when evaluating the prognostic value of high-risk plaque. Importantly, patients with high-risk plaque features often have extensive coronary atherosclerosis with large plaque burden. Furthermore, atherosclerosis …