By Katherine Anderson
Results of a large multicenter prospective study using data from the PROMISE trial provide new evidence that both current and former smokers have a higher burden of coronary plaque. Nóra Melinda Kerkovits, MD, presented the study’s results during a Monday morning session.
Despite widespread awareness that smoking is a major driver of cardiovascular disease and mortality, hundreds of millions of people worldwide continue to smoke, placing a significant strain on health care systems, noted Dr. Kerkovits, a postdoctoral research fellow at the Cardiovascular Imaging Research Center at Massachusetts General Hospital and Harvard Medical School, and radiology resident at Semmelweis University in Budapest, Hungary.
“While prior studies have linked smoking to certain CT-derived measures of coronary artery disease, robust data connecting these imaging findings to clinical outcomes, particularly studies incorporating both qualitative and quantitative analyses, remain limited,” Dr. Kerkovits said. “With coronary CT angiography (CTA) now widely used, we have a powerful, non-invasive way to explore how smoking influences plaque characteristics and whether that helps explain the higher cardiovascular risk smokers face.”
To evaluate the connections between smoking, CT-derived plaque characteristics, and adverse cardiovascular events, Dr. Kerkovits and colleagues analyzed data from the PROMISE trial, a large multicenter study that evaluated noninvasive testing strategies for stable chest pain.
A total of 4,402 patients from the trial with stable chest pain, suspected coronary artery disease and analyzable CT data were included. The average patient age was 61. About 51% of the patients had smoked at some point in their lives and 18% were current smokers.
The researchers assessed qualitative measures, such as calcium score, high-risk plaque features, obstructive stenosis and Leaman score, along with quantitative plaque parameters, such as plaque volume, including total, calcified, non-calcified and low-density plaque.“We hope that the associations we present between smoking, plaque characteristics (both qualitative and quantitative) and major adverse cardiovascular events will aid risk stratification in individuals with a history of smoking, and empower clinicians to promote smoking cessation using personalized, imaging-based evidence.”
Nóra Melinda Kerkovits, MD
Smokers were significantly more likely than non-smokers to have any coronary plaque, obstructive coronary artery disease or high-risk plaque features and showed greater plaque volume across all subtypes.
Smoking was linked to a higher risk of death, non-fatal myocardial infarction or unstable angina hospitalization up to three years after the baseline CTA. Importantly, statistical analysis showed that plaque volumes explained up to 17% of smoking’s impact on adverse cardiovascular outcomes.
By linking imaging findings to clinical outcomes, the team’s analysis bridges a crucial evidence gap between CT-derived plaque characteristics and real-world cardiovascular events.
“Our study provides new evidence that smoking is associated with worse clinical outcomes, mediated in part by adverse plaque characteristics,” Dr. Kerkovits said. “CT-derived plaque characterization may aid risk stratification in stable chest pain patients with a history of smoking.”
Dr. Kerkovits noted that as more plaque analysis tools gain FDA approval, radiologists and clinicians may increasingly encounter detailed plaque characterization in routine reports.
“We hope that the associations we present between smoking, plaque characteristics (both qualitative and quantitative) and major adverse cardiovascular events will aid risk stratification in individuals with a history of smoking, and empower clinicians to promote smoking cessation using personalized, imaging-based evidence,” Dr. Kerkovits concluded.
Access the presentation, “Smokers Show Distinct Coronary CTA Plaque Features and Elevated Risk: Results from The PROMISE Trial,” (M1-SSCA03-2) on demand at RSNA.org/MeetingCentral
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The RSNA 2025 Daily Bulletin is the official publication of the 110th Scientific Assembly and Annual Meeting of the Radiological Society of North America. Published online Sunday, November 30 — Thursday, December 4.
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