The Atherosclerosis Profile by Coronary Computed Tomography Angiography (CTA) in Symptomatic Patients with Coronary Artery Calcium Score Zero.

(1) Background: Whether it is safe to exclude coronary artery disease (CAD) in symptomatic patients with coronary artery calcium score (CACS 0), is an open debate. To compare coronary CTA including high-risk plaque (HRP) features in symptomatic patients with CACS 0 (2) Methods: 1709 symptomatic patients (age, mean 57.5 ± 16 years, 39.6% females) referred to coronary CTA for clinical indications were included. CACS, coronary stenosis (CADRADS) severity and HRP features (low-attenuation-plaque, spotty calcification, positive remodeling, NRS) were recorded. (3) Results: Of 1709 patients, 665 with CACS 0 were finally included. 562 (84.5%) had no CAD by CTA while 103 of 665 (15.4%) had CAD. Stenosis was minimal <25% in 79, mild <50% in 20, moderate in 1 and severe >70% in 3 patients. The rate of obstructive CAD was low with 4/665 (0.61%). The majority of patients had non-obstructive CAD (<50% stenosis) (99/103; 96.1%). A high proportion of patients with non-obstructive CAD had at least one HRP (52/103; 50.4%) per patient. (4) Conclusions: The rate of obstructive CAD is very low in symptomatic patients with CACS 0, and non-obstructive CAD domineering. CACS 0 does not rule out non-obstructive CAD and misses patients in which primary preventive measures are indicated. More than half of patients with non-obstructive CAD had high-risk plaque, highlighting the importance of quantitative plaque analysis.