BACKGROUND:Invasive intracoronary imaging represents the gold standard for identifying vulnerable coronary plaques, but it is not suitable for widespread clinical use. Coronary computed tomography angiography (CTA) may offer a noninvasive alternative. OBJECTIVES:This study aims to integrate coronary CTA-derived plaque morphology, pericoronary inflammation, and plaque burden into a unified morphology-inflammation-burden (MIB) score and to evaluate its association with plaque vulnerability and clinical outcomes. METHODS:Patients undergoing coronary CTA followed by optical coherence tomography (OCT) and intravascular ultrasound (IVUS) were followed for a median of 31 months. High-risk plaque, pericoronary adipose tissue attenuation, and total plaque burden (TPB) were quantified and compared with invasive imaging. A vulnerable lesion was defined as ≥2 vulnerability features on OCT. RESULTS:A total of 438 patients (median age 67 years) and 1,038 plaques were included; 45.4% presented with non-ST-segment elevation acute coronary syndrome. High-risk plaque, elevated pericoronary adipose tissue attenuation, and high TPB were independently associated with OCT-defined vulnerability (P < 0.05 for all). TPB correlated with IVUS percent atheroma volume (Pearson's r = 0.69; P < 0.001). The MIB score demonstrated a stepwise increase in vulnerability, exceeding a predicted risk of 90% in the highest category. Vulnerable patients, defined by the presence of ≥1 untreated lesion with a high MIB score, had a significantly higher rate of cardiac death, acute coronary syndrome, or revascularization (15.3% vs 4.4%; P < 0.001). CONCLUSIONS:A coronary CTA-derived MIB score correlates with plaque vulnerability by intracoronary imaging and identifies patients at increased risk for adverse events. These findings support the value of coronary CTA for noninvasive risk stratification in clinical practice. (Massachusetts General Hospital and Tsuchiura Kyodo General Hospital Coronary Imaging Collaboration; NCT04523194).
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