Skip to main content

Subclinical atherosclerosis detected by coronary computed tomographic angiography in Qatar: a comparison between Qataris and south Asian migrants



There are limited data regarding subclinical atherosclerosis in Middle Eastern countries. We aimed to describe and compare coronary computed tomographic angiography (CCTA) findings in Qatari native and South Asian migrants at increased risk of coronary artery disease (CAD).


We performed CCTA in 251 consecutive volunteers (126 South Asian, 125 Qatari, mean age 50.0 ± 7.3 years, 27.1% female) at increased risk of cardiovascular disease. Given differences in baseline risk factors, we employed propensity score matching to create a cohort of 162 subjects for comparative analyses. We compared CAD severity, extent, plaque morphology, adverse plaque characteristics, and quantitative measures of atherosclerotic burden in both subgroups.


After matching, no CAD was seen in 58.0% of South Asians and 49.4% of Qataris (p = 0.3), while obstructive CAD (≥50% luminal stenosis) was present in 40.7% of South Asians and 49.4% of Qataris (p = 0.3). There was a high prevalence of adverse plaque characteristics in both ethnicities, particularly positive remodeling. South Asians had significantly smaller vessel and lumen volumes, but the percent aggregate plaque volumes were not significantly different (2.9 ± 6.3% vs. 3.8 ± 8.0%, p = 0.4).


In this first study of CCTA findings performed in a Middle Eastern country, we observed a high prevalence of obstructive CAD in a middle-aged cohort. There were no significant differences in CCTA findings between Qataris and South Asians after adjustment for clinical risk factors. Future studies are needed to identify patterns of coronary atherosclerosis by CCTA in non-European populations where cardiovascular disease is increasingly prevalent.

This is a preview of subscription content, access via your institution.

Fig. 1



% Aggregate plaque volume


Coronary artery calcium


Coronary artery disease


Coronary computed tomographic angiography


Left main


Segment involvement score


Segment stenosis score


Weill Cornell Medical College


  1. Mokdad AH, Jaber S, Aziz MI, AlBuhairan F, AlGhaithi A, AlHamad NM, Al-Hooti SN et al (2014) The state of health in the Arab world, 1990–2010: an analysis of the burden of diseases, injuries, and risk factors. Lancet 383(9914):309–320. doi:10.1016/S0140-6736(13)62189-3

    Article  PubMed  Google Scholar 

  2. Roth GA, Huffman MD, Moran AE, Feigin V, Mensah GA, Naghavi M, Murray CJ (2015) Global and regional patterns in cardiovascular mortality from 1990 to 2013. Circulation 132(17):1667–1678. doi:10.1161/CIRCULATIONAHA.114.008720

    Article  PubMed  Google Scholar 

  3. Rahim HF, Sibai A, Khader Y, Hwalla N, Fadhil I, Alsiyabi H, Mataria A et al (2014) Non-communicable diseases in the Arab world. Lancet 383(9914):356–367. doi:10.1016/S0140-6736(13)62383-1

    Article  PubMed  Google Scholar 

  4. Gupta M, Singh N, Verma S (2006) South Asians and cardiovascular risk: what clinicians should know. Circulation 113(25):e924–e929. doi:10.1161/CIRCULATIONAHA.105.583815

    Article  PubMed  Google Scholar 

  5. Detrano R, Guerci AD, Carr JJ, Bild DE, Burke G, Folsom AR, Liu K et al (2008) Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med 358(13):1336–1345. doi:10.1056/NEJMoa072100

    CAS  Article  PubMed  Google Scholar 

  6. Min JK, Dunning A, Lin FY, Achenbach S, Al-Mallah M, Budoff MJ, Cademartiri F et al (2011) Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: an International Multicenter Registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol 58(8):849–860

    Article  PubMed  Google Scholar 

  7. Mushtaq S, De Araujo Goncalves P, Garcia-Garcia HM, Pontone G, Bartorelli AL, Bertella E, Campos CM et al (2015) Long-term prognostic effect of coronary atherosclerotic burden: validation of the computed tomography-Leaman score. Circ Cardiovasc Imaging 8(2):e002332. doi:10.1161/CIRCIMAGING.114.002332

    Article  PubMed  Google Scholar 

  8. Bild DE, Detrano R, Peterson D, Guerci A, Liu K, Shahar E, Ouyang P et al (2005) Ethnic differences in coronary calcification: the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation 111(10):1313–1320. doi:10.1161/01.CIR.0000157730.94423.4B

    Article  PubMed  Google Scholar 

  9. McClelland RL, Chung H, Detrano R, Post W, Kronmal RA (2006) Distribution of coronary artery calcium by race, gender, and age: results from the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation 113(1):30–37. doi:10.1161/CIRCULATIONAHA.105.580696

    Article  PubMed  Google Scholar 

  10. Hulten E, Villines TC, Cheezum MK, Berman DS, Dunning A, Achenbach S, Al-Mallah M et al (2013) Usefulness of coronary computed tomography angiography to predict mortality and myocardial infarction among Caucasian, African and East Asian ethnicities (from the CONFIRM [Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter] Registry). Am J Cardiol 111(4):479–485. doi:10.1016/j.amjcard.2012.10.028

    Article  PubMed  Google Scholar 

  11. Abbara S, Arbab-Zadeh A, Callister TQ, Desai MY, Mamuya W, Thomson L, Weigold WG (2009) SCCT guidelines for performance of coronary computed tomographic angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr 3(3):190–204. doi:10.1016/j.jcct.2009.03.004

    Article  PubMed  Google Scholar 

  12. Raff GL, Abidov A, Achenbach S, Berman DS, Boxt LM, Budoff MJ, Cheng V et al (2009) SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography. J Cardiovasc Comput Tomogr 3(2):122–136. doi:10.1016/j.jcct.2009.01.001

    Article  PubMed  Google Scholar 

  13. Min JK, Shaw LJ, Devereux RB, Okin PM, Weinsaft JW, Russo DJ, Lippolis NJ et al (2007) Prognostic value of multidetector coronary computed tomographic angiography for prediction of all-cause mortality. J Am Coll Cardiol 50(12):1161–1170. doi:10.1016/j.jacc.2007.03.067

    Article  PubMed  Google Scholar 

  14. Motoyama S, Sarai M, Harigaya H, Anno H, Inoue K, Hara T, Naruse H et al (2009) Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute coronary syndrome. J Am Coll Cardiol 54(1):49–57. doi:10.1016/j.jacc.2009.02.068

    Article  PubMed  Google Scholar 

  15. Boogers MJ, Broersen A, van Velzen JE, de Graaf FR, El-Naggar HM, Kitslaar PH, Dijkstra J et al (2012) Automated quantification of coronary plaque with computed tomography: comparison with intravascular ultrasound using a dedicated registration algorithm for fusion-based quantification. Eur Heart J 33(8):1007–1016. doi:10.1093/eurheartj/ehr465

    Article  PubMed  Google Scholar 

  16. de Graaf MA, Broersen A, Kitslaar PH, Roos CJ, Dijkstra J, Lelieveldt BP, Jukema JW et al (2013) Automatic quantification and characterization of coronary atherosclerosis with computed tomography coronary angiography: cross-correlation with intravascular ultrasound virtual histology. Int J Cardiovasc Imaging 29(5):1177–1190. doi:10.1007/s10554-013-0194-x

    Article  PubMed  Google Scholar 

  17. Nasir K, Rubin J, Blaha MJ, Shaw LJ, Blankstein R, Rivera JJ, Khan AN et al (2012) Interplay of coronary artery calcification and traditional risk factors for the prediction of all-cause mortality in asymptomatic individuals. Circ Cardiovasc Imaging 5:467–473. doi:10.1161/CIRCIMAGING.111.964528

    Article  PubMed  Google Scholar 

  18. Cho I, Chang H-J, Sung JM, Pencina MJ, Lin FY, Dunning AM, Achenbach S et al (2012) Coronary computed tomographic angiography and risk of all-cause mortality and nonfatal myocardial infarction in subjects without chest pain syndrome from the CONFIRM Registry (coronary CT angiography evaluation for clinical outcomes: an international mult. Circulation 126:304–313. doi:10.1161/CIRCULATIONAHA.111.081380

    Article  PubMed  Google Scholar 

  19. Hatwalkar A, Agrawal N, Reiss DS, Budoff MJ (2003) Comparison of prevalence and severity of coronary calcium determined by electron beam tomography among various ethnic groups. Am J Cardiol 91(10):1225–1227

    CAS  Article  PubMed  Google Scholar 

  20. Kanaya AM, Kandula NR, Ewing SK, Herrington D, Liu K, Blaha MJ, Srivastava S et al (2014) Comparing coronary artery calcium among U.S. South Asians with four racial/ethnic groups: the MASALA and MESA studies. Atherosclerosis 234(1):102–107. doi:10.1016/j.atherosclerosis.2014.02.017

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  21. Fathala A, Alreshoodi S, Rujaib MA, Shoukri M, Sergani HA, Buriki JA, Sugair AA (2015) Coronary artery calcium score in high-risk asymptomatic women in Saudi Arabia. Ann Saudi Med 35(4):298–302. doi:10.5144/0256-4947.2015.298

    Article  PubMed  Google Scholar 

  22. Cho I, Chang HJ, B OH, Shin S, Sung JM, Lin FY, Achenbach S et al (2015) Incremental prognostic utility of coronary CT angiography for asymptomatic patients based upon extent and severity of coronary artery calcium: results from the COronary CT Angiography EvaluatioN For Clinical Outcomes InteRnational Multicenter (CONFIRM) Study. Eur Heart J 36(8):501–508. doi:10.1093/eurheartj/ehu358

    Article  PubMed  Google Scholar 

  23. Nadjiri J, Hausleiter J, Jahnichen C, Will A, Hendrich E, Martinoff S, Hadamitzky M (2016) Incremental prognostic value of quantitative plaque assessment in coronary CT angiography during 5 years of follow up. J Cardiovasc Comput Tomogr 10(2):97–104. doi:10.1016/j.jcct.2016.01.007

    Article  PubMed  Google Scholar 

  24. Park HB, Heo R, B OH, Cho I, Gransar H, Nakazato R, Leipsic J et al (2015) Atherosclerotic plaque characteristics by CT angiography identify coronary lesions that cause ischemia: a direct comparison to fractional flow reserve. JACC Cardiovasc Imaging 8(1):1–10. doi:10.1016/j.jcmg.2014.11.002

    Article  PubMed  PubMed Central  Google Scholar 

  25. Gehani AA, Al-Hinai AT, Zubaid M, Almahmeed W, Hasani MR, Yusufali AH, Hassan MO et al (2014) Association of risk factors with acute myocardial infarction in Middle Eastern countries: the INTERHEART Middle East study. Eur J Prev Cardiol 21(4):400–410. doi:10.1177/2047487312465525

    Article  PubMed  Google Scholar 

  26. Fernando E, Razak F, Lear SA, Anand SS (2015) Cardiovascular disease in South Asian migrants. Can J Cardiol 31(9):1139–1150. doi:10.1016/j.cjca.2015.06.008

    Article  PubMed  Google Scholar 

  27. Koulaouzidis G, Nicoll R, Charisopoulou D, McArthur T, Jenkins PJ, Henein MY (2013) Aggressive and diffuse coronary calcification in South Asian angina patients compared to Caucasians with similar risk factors. Int J Cardiol 167(6):2472–2476. doi:10.1016/j.ijcard.2012.05.102

    CAS  Article  PubMed  Google Scholar 

  28. Roos CJ, Kharagjitsingh AV, Jukema JW, Bax JJ, Scholte AJ (2014) Comparison by computed tomographic angiography-the presence and extent of coronary arterial atherosclerosis in South Asians versus Caucasians with diabetes mellitus. Am J Cardiol 113(11):1782–1787. doi:10.1016/j.amjcard.2014.03.005

    Article  PubMed  Google Scholar 

  29. Panduranga P, Sulaiman KJ, Al-Zakwani I, Alhabib KF, Hersi A, Suwaidi JA, Alsheikh-Ali AA et al (2015) Acute coronary syndrome in Indian subcontinent patients residing in the Middle East: results from Gulf Registry of Acute Coronary Events II. Angiology 66(9):818–825. doi:10.1177/0003319714556812

    CAS  Article  PubMed  Google Scholar 

  30. Muhlestein JB, Lappe DL, Lima JA, Rosen BD, May HT, Knight S, Bluemke DA et al (2014) Effect of screening for coronary artery disease using CT angiography on mortality and cardiac events in high-risk patients with diabetes: the FACTOR-64 randomized clinical trial. JAMA 312(21):2234–2243. doi:10.1001/jama.2014.15825

    CAS  Article  PubMed  Google Scholar 

  31. Makaryus AN, Dhama B, Raince J, Raince A, Garyali S, Labana SS, Kaplan BM et al (2005) Coronary artery diameter as a risk factor for acute coronary syndromes in Asian–Indians. Am J Cardiol 96(6):778–780. doi:10.1016/j.amjcard.2005.05.018

    Article  PubMed  Google Scholar 

  32. Tillin T, Dhutia H, Chambers J, Malik I, Coady E, Mayet J, Wright AR et al (2008) South Asian men have different patterns of coronary artery disease when compared with European men. Int J Cardiol 129(3):406–413. doi:10.1016/j.ijcard.2007.07.129

    Article  PubMed  Google Scholar 

  33. Hasan RK, Ginwala NT, Shah RY, Kumbhani DJ, Wilensky RL, Mehta NN (2011) Quantitative angiography in South Asians reveals differences in vessel size and coronary artery disease severity compared to Caucasians. Am J Cardiovasc Dis 1(1):31–37

    PubMed  PubMed Central  Google Scholar 

  34. Zindrou D, Taylor KM, Bagger JP (2006) Coronary artery size and disease in UK South Asian and Caucasian men. Eur J Cardiothorac Surg 29(4):492–495. doi:10.1016/j.ejcts.2006.01.008

    Article  PubMed  Google Scholar 

Download references


All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.


This study was supported by the Qatar National Research Fund (NPRP 09-370-3-089) and in part, by a generous gift from the Dalio Institute of Cardiovascular Imaging (New York, NY, USA) and the Michael Wolk Foundation (New York, NY, USA). The funding agencies were not involved in the study design; collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the article for publication.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Jessica M. Peña.

Ethics declarations

Conflict of interest

James K. Min reports being a consultant with HeartFlow, on the scientific advisory board of Arineta, having partial ownership in MDDX and Autoplaq, and receiving research support from GE Healthcare. All other authors have no relevant disclosures.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Schulman-Marcus, J., Heo, R., Gransar, H. et al. Subclinical atherosclerosis detected by coronary computed tomographic angiography in Qatar: a comparison between Qataris and south Asian migrants. Int J Cardiovasc Imaging 33, 927–935 (2017).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Coronary computed tomographic angiography
  • Atherosclerosis
  • Ethnicity