Cleerly, a leader in advanced cardiovascular imaging analysis, today announced findings from a study of 1,385 patients with suspected coronary artery disease (CAD) presented at the European Society of Cardiology (ESC) Congress 2026 in Munich. The study, titled “Temporal associations of coronary plaque burden and myocardial perfusion with clinical outcomes,” was led by Jorge Dahdal, MD, of Clínica Alemana de Santiago, Chile, and Amsterdam UMC, the Netherlands, and presented on August 30 by co-author Ruurt Jukema from Amsterdam UMC. The research is published simultaneously in the European Journal of Nuclear Medicine and Molecular Imaging (EJNMMI) under the title “Time-Dependent Prognostic Value of Coronary Plaque Burden and Hyperemic Myocardial Blood Flow.” The study evaluated the prognostic associations of quantitative plaque burden and myocardial blood flow over time.

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The study compared two ways of measuring coronary artery disease in the same patients: the structural extent of coronary plaque, quantified from coronary CT angiography (CCTA) using AI-based quantitative coronary CT analysis (AI-QCT) and expressed as percent atheroma volume (PAV); and the functional consequence of that disease, measured as regional hyperemic myocardial blood flow (hMBF) using [15O]H₂O positron emission tomography (PET), an advanced imaging test used to measure how well blood is flowing into the heart muscle. Patients were followed for a median of 7.1 years, during which 185 (13.4%) experienced the composite outcome of all-cause mortality, non-fatal myocardial infarction, or unstable angina.

The analysis is notable for assessing both markers together in adjusted models at three separate time horizons (3, 6, and 9 years) in a large cohort with both AI-quantified plaque and quantitative PET perfusion data, allowing the two measures to be compared directly over time rather than at a single endpoint.

Key Findings

  • Plaque burden was consistently associated with increased event rates over time. Even after accounting for blood flow, higher percent atheroma volume was associated with increased event rates at every timepoint assessed (adjusted hazard ratio 1.035–1.047 per 1% PAV; all p < 0.001).

  • Blood flow was independently associated with events at 3 and 6 years. Even after accounting for plaque burden, lower regional hyperemic myocardial blood flow was associated with events at three years (aHR 1.050 per 0.1 mL/min/g, p = 0.004) and six years (aHR 1.028, p = 0.024), but the association was not statistically significant at nine years (aHR 1.020, p = 0.063).

  • Regional hyperemic myocardial blood flow remained associated with outcomes after excluding early revascularization. When patients who underwent early revascularization were excluded from the analysis, reduced hyperemic myocardial blood flow remained associated with adverse outcomes at all three timepoints.

Implications for Cardiovascular Risk Assessment

Structure and function carried different prognostic time courses. Plaque burden was associated with events throughout follow-up, while regional hyperemic myocardial blood flow measured by PET was primarily associated with short- and intermediate-term events. The authors note this finding pertains to this specific stress-only perfusion measure and may not extend to flow reserve indices or other PET tracers.

The findings help explain differences in prior data. Previous studies have disagreed on whether PET-measured myocardial blood flow adds prognostic value beyond anatomical measures of atherosclerosis. The revascularization analysis offers a potential explanation for these differences.

Quantitative plaque assessment may support long-term risk stratification. Because the association between plaque burden and events persisted at every timepoint assessed, PAV may provide prognostic information for longer-term cardiovascular risk.

“These findings argue for viewing anatomical and functional assessment as complementary rather than competing. Quantitative plaque burden appears to capture durable, long-horizon risk, while stress myocardial blood flow identifies patients at nearer-term risk who may benefit from earlier intervention. Together they provide a more complete picture of a patient’s disease than either measure alone,” said Jorge Dahdal, MD, cardiology resident at Clínica Alemana de Santiago, Santiago, Chile, and PhD candidate at Amsterdam UMC, Amsterdam, the Netherlands, on behalf of the study investigators.

About Cleerly

Cleerly is the company on a mission to eliminate heart attacks by creating a new standard of care for heart disease. Through its FDA-cleared solutions driven by artificial intelligence, Cleerly supports comprehensive phenotyping of coronary artery disease, as determined from advanced noninvasive CT imaging. Cleerly’s approach is grounded in science, based on millions of images from over 40,000 patients. Led by a world-class clinical and technical team, Cleerly enhances health literacy for each and every stakeholder in the coronary care pathway. For more information, please visit: cleerly.com.

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