CAD-RADS 2.0 and CTA-Based Risk Stratification for Long-Term MACE Prediction: C-CORE Registry

This prospective registry analysis from the C-CORE (Coronary CTA Risk Stratification) program evaluated 24,931 patients undergoing CCTA, applying the CAD-RADS 2.0 reporting system — which integrates both stenosis severity and plaque characterization features — to predict long-term MACE (major adverse cardiovascular events) over 5-year follow-up.

CAD-RADS 2.0 — which adds plaque characterization (high-risk plaque features: low-attenuation plaque, spotty calcification, positive remodeling, napkin-ring sign) to the stenosis-based CAD-RADS 1.0 scoring — significantly improved MACE prediction beyond stenosis alone. Patients with high-risk plaque features demonstrated substantially elevated MACE rates even at moderate stenosis severity; patients without high-risk plaque features at equivalent stenosis had significantly lower event rates. The comprehensive score improved C-statistic for MACE prediction by approximately 0.04–0.06 over stenosis-only classification.

This registry represents one of the largest outcome datasets directly comparing plaque characterization-enhanced versus stenosis-only CCTA risk stratification. The finding that plaque features improve MACE prediction aligns with IVUS-based PROSPECT trial data (Stone et al., 2011) showing that vulnerable plaque morphology — not stenosis severity alone — determines who has future events.

For clinical practice, this study supports adopting comprehensive CCTA plaque characterization (not just stenosis grading) as the standard reporting approach, with high-risk plaque features triggering more intensive preventive treatment regardless of stenosis severity.

We rate the evidence strong. A large registry study in 24,931 patients demonstrating that CCTA plaque characterization (CAD-RADS 2.0) significantly improves long-term MACE prediction beyond stenosis-only assessment — important validation for comprehensive CCTA reporting as the clinical standard.