Can We Measure Vulnerable Plaques on Coronary CT Angiography with Both Precision and Accuracy?

This editorial examined the methodological challenges of measuring vulnerable plaque features — particularly low-attenuation plaque burden — on coronary CT angiography with sufficient precision and accuracy to add clinical value beyond stenosis assessment.

The authors argue that quantitative plaque metrics, including low-attenuation plaque burden, improve risk stratification beyond stenosis alone. They note that precision (reproducibility) and accuracy (agreement with histological ground truth) are both necessary for clinical deployment — and that current CT technology approaches but has not fully achieved both simultaneously.

The editorial highlights an important limitation of CCTA-based plaque characterization: individual plaque features identifiable on CT (low density, positive remodeling, pericoronary fat attenuation) are correlated with histological vulnerability, but their quantification varies with CT acquisition parameters, reconstruction algorithms, and plaque composition. Improvements in photon-counting CT and standardized protocols are active areas of development.

We rate the evidence limited. An expert editorial framing a measurement challenge in CCTA-based plaque assessment — useful for contextualizing the literature on CCTA vulnerability features, but not a primary evidence source.