Skip to main content


Log in

Standardized volumetric plaque quantification and characterization from coronary CT angiography: a head-to-head comparison with invasive intravascular ultrasound

  • Cardiac
  • Published:
European Radiology Aims and scope Submit manuscript



We sought to evaluate the accuracy of standardized total plaque volume (TPV) measurement and low-density non-calcified plaque (LDNCP) assessment from coronary CT angiography (CTA) in comparison with intravascular ultrasound (IVUS).


We analyzed 118 plaques without extensive calcifications from 77 consecutive patients who underwent CTA prior to IVUS. CTA TPV was measured with semi-automated software comparing both scan-specific (automatically derived from scan) and fixed attenuation thresholds. From CTA, %LDNCP was calculated voxels below multiple LDNCP thresholds (30, 45, 60, 75, and 90 Hounsfield units [HU]) within the plaque. On IVUS, the lipid-rich component was identified by echo attenuation, and its size was measured using attenuation score (summed score ∕ analysis length) based on attenuation arc (1 = < 90°; 2 = 90–180°; 3 = 180–270°; 4 = 270–360°) every 1 mm.


TPV was highly correlated between CTA using scan-specific thresholds and IVUS (r = 0.943, p < 0.001), with no significant difference (2.6 mm3, p = 0.270). These relationships persisted for calcification patterns (maximal IVUS calcium arc of 0°, < 90°, or ≥ 90°). The fixed thresholds underestimated TPV (− 22.0 mm3, p < 0.001) and had an inferior correlation with IVUS (p < 0.001) compared with scan-specific thresholds. A 45-HU cutoff yielded the best diagnostic performance for identification of lipid-rich component, with an area under the curve of 0.878 vs. 0.840 for < 30 HU (p = 0.023), and corresponding %LDNCP resulted in the strongest correlation with the lipid-rich component size (r = 0.691, p < 0.001).


Standardized noninvasive plaque quantification from CTA using scan-specific thresholds correlates highly with IVUS. Use of a < 45-HU threshold for LDNCP quantification improves lipid-rich plaque assessment from CTA.

Key Points

Standardized scan-specific threshold-based plaque quantification from coronary CT angiography provides an accurate total plaque volume measurement compared with intravascular ultrasound.

Attenuation histogram-based low-density non-calcified plaque quantification can improve lipid-rich plaque assessment from coronary CT angiography.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others



Coronary CT angiography


Hounsfield units


Interquartile range


Intravascular ultrasound


Low-density non-calcified plaque


Total plaque volume


  1. Kolodgie FD, Burke AP, Farb A et al (2001) The thin-cap fibroatheroma: a type of vulnerable plaque: the major precursor lesion to acute coronary syndromes. Curr Opin Cardiol 16:285–292

    Article  CAS  Google Scholar 

  2. Maurovich-Horvat P, Ferencik M, Voros S, Merkely B, Hoffmann U (2014) Comprehensive plaque assessment by coronary CT angiography. Nat Rev Cardiol 11:390–402

    Article  Google Scholar 

  3. Falk E, Nakano M, Bentzon JF, Finn AV, Virmani R (2013) Update on acute coronary syndromes: the pathologists’ view. Eur Heart J 34:719–728

    Article  CAS  Google Scholar 

  4. Motoyama S, Kondo T, Anno H et al (2007) Atherosclerotic plaque characterization by 0.5-mm-slice multislice computed tomographic imaging. Circ J 71:363–366

    Article  Google Scholar 

  5. Marwan M, Taher MA, El Meniawy K et al (2011) In vivo CT detection of lipid-rich coronary artery atherosclerotic plaques using quantitative histogram analysis: a head to head comparison with IVUS. Atherosclerosis 215:110–115

    Article  CAS  Google Scholar 

  6. Han D, Torii S, Yahagi K et al (2018) Quantitative measurement of lipid rich plaque by coronary computed tomography angiography: a correlation of histology in sudden cardiac death. Atherosclerosis 275:426–433

    Article  CAS  Google Scholar 

  7. Obaid DR, Calvert PA, Gopalan D et al (2013) Atherosclerotic plaque composition and classification identified by coronary computed tomography: assessment of computed tomography-generated plaque maps compared with virtual histology intravascular ultrasound and histology. Circ Cardiovasc Imaging 6:655–664

    Article  Google Scholar 

  8. Motoyama S, Kondo T, Sarai M et al (2007) Multislice computed tomographic characteristics of coronary lesions in acute coronary syndromes. J Am Coll Cardiol 50:319–326

    Article  Google Scholar 

  9. Motoyama S, Ito H, Sarai M et al (2015) Plaque characterization by coronary computed tomography angiography and the likelihood of acute coronary events in mid-term follow-up. J Am Coll Cardiol 66:337–346

    Article  Google Scholar 

  10. Horiguchi J, Fujioka C, Kiguchi M et al (2007) Soft and intermediate plaques in coronary arteries: how accurately can we measure CT attenuation using 64-MDCT? AJR Am J Roentgenol 189:981–988

    Article  Google Scholar 

  11. Dey D, Achenbach S, Schuhbaeck A et al (2014) Comparison of quantitative atherosclerotic plaque burden from coronary CT angiography in patients with first acute coronary syndrome and stable coronary artery disease. J Cardiovasc Comput Tomogr 8:368–374

    Article  Google Scholar 

  12. Gaur S, Ovrehus KA, Dey D et al (2016) Coronary plaque quantification and fractional flow reserve by coronary computed tomography angiography identify ischaemia-causing lesions. Eur Heart J 37:1220–1227

    Article  Google Scholar 

  13. Hell MM, Motwani M, Otaki Y et al (2017) Quantitative global plaque characteristics from coronary computed tomography angiography for the prediction of future cardiac mortality during long-term follow-up. Eur Heart J Cardiovasc Imaging 18:1331–1339

    Article  Google Scholar 

  14. Chang HJ, Lin FY, Lee SE et al (2018) Coronary atherosclerotic precursors of acute coronary syndromes. J Am Coll Cardiol 71:2511–2522

    Article  Google Scholar 

  15. Mintz GS, Nissen SE, Anderson WD et al (2001) American College of Cardiology Clinical Expert Consensus Document on Standards for Acquisition, Measurement and Reporting of Intravascular Ultrasound Studies (IVUS). A report of the American College of Cardiology Task Force on cClinical Expert Consensus Documents. J Am Coll Cardiol 37:1478–1492

    Article  CAS  Google Scholar 

  16. Matsumoto H, Watanabe S, Kyo E et al (2019) Effect of tube potential and luminal contrast attenuation on atherosclerotic plaque attenuation by coronary CT angiography: in vivo comparison with intravascular ultrasound. J Cardiovasc Comput Tomogr, in press.

  17. Stone GW, Maehara A, Lansky AJ et al (2011) A prospective natural-history study of coronary atherosclerosis. N Engl J Med 364:226–235

    Article  CAS  Google Scholar 

  18. van der Giessen AG, Toepker MH, Donelly PM et al (2010) Reproducibility, accuracy, and predictors of accuracy for the detection of coronary atherosclerotic plaque composition by computed tomography: an ex vivo comparison to intravascular ultrasound. Invest Radiol 45:693–701

    Article  Google Scholar 

  19. Ehara S, Kobayashi Y, Yoshiyama M et al (2004) Spotty calcification typifies the culprit plaque in patients with acute myocardial infarction: an intravascular ultrasound study. Circulation 110:3424–3429

    Article  Google Scholar 

  20. Shiono Y, Kubo T, Tanaka A et al (2013) Impact of attenuated plaque as detected by intravascular ultrasound on the occurrence of microvascular obstruction after percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction. JACC Cardiovasc Interv 6:847–853

    Article  Google Scholar 

  21. Pu J, Mintz GS, Biro S et al (2014) Insights into echo-attenuated plaques, echolucent plaques, and plaques with spotty calcification: novel findings from comparisons among intravascular ultrasound, near-infrared spectroscopy, and pathological histology in 2,294 human coronary artery segments. J Am Coll Cardiol 63:2220–2233

    Article  Google Scholar 

  22. Kang SJ, Mintz GS, Pu J et al (2015) Combined IVUS and NIRS detection of fibroatheromas: histopathological validation in human coronary arteries. JACC Cardiovasc Imaging 8:184–194

    Article  Google Scholar 

  23. Pu J, Mintz GS, Brilakis ES et al (2012) In vivo characterization of coronary plaques: novel findings from comparing greyscale and virtual histology intravascular ultrasound and near-infrared spectroscopy. Eur Heart J 33:372–383

    Article  Google Scholar 

  24. Wu X, Mintz GS, Xu K et al (2011) The relationship between attenuated plaque identified by intravascular ultrasound and no-reflow after stenting in acute myocardial infarction: the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial. JACC Cardiovasc Interv 4:495–502

    Article  Google Scholar 

  25. Dey D, Cheng VY, Slomka PJ et al (2009) Automated 3-dimensional quantification of noncalcified and calcified coronary plaque from coronary CT angiography. J Cardiovasc Comput Tomogr 3:372–382

    Article  Google Scholar 

  26. Dey D, Schepis T, Marwan M, Slomka PJ, Berman DS, Achenbach S (2010) Automated three-dimensional quantification of noncalcified coronary plaque from coronary CT angiography: comparison with intravascular US. Radiology 257:516–522

    Article  Google Scholar 

  27. Cheng VY, Nakazato R, Dey D et al (2009) Reproducibility of coronary artery plaque volume and composition quantification by 64-detector row coronary computed tomographic angiography: an intraobserver, interobserver, and interscan variability study. J Cardiovasc Comput Tomogr 3:312–320

    Article  Google Scholar 

  28. Park HB, Lee BK, Shin S et al (2015) Clinical feasibility of 3D automated coronary atherosclerotic plaque quantification algorithm on coronary computed tomography angiography: comparison with intravascular ultrasound. Eur Radiol 25:3073–3083

    Article  Google Scholar 

  29. Komatsu S, Hirayama A, Omori Y et al (2005) Detection of coronary plaque by computed tomography with a novel plaque analysis system, ‘Plaque Map’, and comparison with intravascular ultrasound and angioscopy. Circ J 69:72–77

    Article  Google Scholar 

  30. Uetani T, Amano T, Kunimura A et al (2010) The association between plaque characterization by CT angiography and post-procedural myocardial infarction in patients with elective stent implantation. JACC Cardiovasc Imaging 3:19–28

    Article  Google Scholar 

  31. Zweig MH, Campbell G (1993) Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool in clinical medicine. Clin Chem 39:561–577

    CAS  Google Scholar 

  32. Nicholls SJ, Ballantyne CM, Barter PJ et al (2011) Effect of two intensive statin regimens on progression of coronary disease. N Engl J Med 365:2078–2087

    Article  CAS  Google Scholar 

  33. Lee SE, Sung JM, Rizvi A et al (2018) Quantification of coronary atherosclerosis in the assessment of coronary artery disease. Circ Cardiovasc Imaging 11:e007562

    Article  Google Scholar 

  34. Nakazato R, Shalev A, Doh JH et al (2013) Aggregate plaque volume by coronary computed tomography angiography is superior and incremental to luminal narrowing for diagnosis of ischemic lesions of intermediate stenosis severity. J Am Coll Cardiol 62:460–467

    Article  Google Scholar 

  35. Cademartiri F, Mollet NR, Runza G et al (2005) Influence of intracoronary attenuation on coronary plaque measurements using multislice computed tomography: observations in an ex vivo model of coronary computed tomography angiography. Eur Radiol 15:1426–1431

    Article  Google Scholar 

  36. Dalager MG, Bottcher M, Andersen G et al (2011) Impact of luminal density on plaque classification by CT coronary angiography. Int J Cardiovasc Imaging 27:593–600

    Article  Google Scholar 

  37. Bae KT (2010) Intravenous contrast medium administration and scan timing at CT: considerations and approaches. Radiology 256:32–61

    Article  Google Scholar 

  38. Narula J, Nakano M, Virmani R et al (2013) Histopathologic characteristics of atherosclerotic coronary disease and implications of the findings for the invasive and noninvasive detection of vulnerable plaques. J Am Coll Cardiol 61:1041–1051

    Article  Google Scholar 

  39. Schlett CL, Maurovich-Horvat P, Ferencik M et al (2013) Histogram analysis of lipid-core plaques in coronary computed tomographic angiography: ex vivo validation against histology. Invest Radiol 48:646–653

    Article  Google Scholar 

  40. Kimura S, Sugiyama T, Hishikari K et al (2015) Association of intravascular ultrasound- and optical coherence tomography-assessed coronary plaque morphology with periprocedural myocardial injury in patients with stable angina pectoris. Circ J 79:1944–1953

    Article  Google Scholar 

  41. Kimura S, Sugiyama T, Hishikari K et al (2018) The clinical significance of echo-attenuated plaque in stable angina pectoris compared with acute coronary syndromes: a combined intravascular ultrasound and optical coherence tomography study. Int J Cardiol 270:1–6

    Article  Google Scholar 

Download references


This work was funded by National Institute of Health/National Heart, Lung, and Blood Institute grant 1R01HL133616 (to Dr. Dey), and partially by a grant from the Miriam and Sheldon G. Adelson Medical Research Foundation.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Hidenari Matsumoto.

Ethics declarations


The scientific guarantor of this publication is Damini Dey, PhD.

Conflict of interest

Damini Dey, Sebastien Cadet, Piotr J Slomka, and Daniel S Berman received software royalties from Cedars-Sinai Medical Center; Damini Dey, Piotr J Slomka, and Daniel S Berman have a patent.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• diagnostic study

• performed at one institution

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material


(DOCX 1905 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Matsumoto, H., Watanabe, S., Kyo, E. et al. Standardized volumetric plaque quantification and characterization from coronary CT angiography: a head-to-head comparison with invasive intravascular ultrasound. Eur Radiol 29, 6129–6139 (2019).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: