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• W1538648639 abstract "The beneficial effect of statins on slowing coronary atherosclerotic plaque progression or even leading to plaque regression has been clearly established with intravascular ultrasound (IVUS) imaging [1Nissen S.E. Nicholls S.J. Sipahi I. Libby P. Raichlen J.S. Ballantyne C.M. et al.Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: the ASTEROID trial.JAMA. 2006; 295: 1556-1565Crossref PubMed Scopus (1713) Google Scholar, 2Nicholls S.J. Ballantyne C.M. Barter P.J. Chapman M.J. Erbel R.M. Libby P. et al.Effect of two intensive statin regimens on progression of coronary disease.N. Engl. J. Med. 2011; 365: 2078-2087Crossref PubMed Scopus (607) Google Scholar]. In fact, the effect of statins on coronary plaque progression/regression appears to be dose-dependent with the larger effect observed with high-intensity statin treatment. Coronary calcium is an integral part of atherosclerotic process with spotty calcification being associated with inflammation and plaque vulnerability and dense calcium associated with more stable plaque phenotypes [3Libby P. How does lipid lowering prevent coronary events? New insights from human imaging trials.Eur. Heart J. 2015; 36: 472-474Crossref PubMed Scopus (37) Google Scholar, 4Joshi N.V. Vesey A.T. Williams M.C. Shah A.S.V. Calvert P.A. Craighead F.H.M. et al.18F-fluoride positron emission tomography for identification of ruptured and high-risk coronary atherosclerotic plaques: a prospective clinical trial.Lancet. 2014; 383: 705-713Abstract Full Text Full Text PDF PubMed Scopus (652) Google Scholar]. Given that the burden of calcified atherosclerotic plaque closely correlates with overall coronary plaque burden as assessed ex vivo by histopathology [[5]Sangiorgi G. Rumberger J.A. Severson A. Edwards W.D. Gregoire J. Fitzpatrick L.A. et al.Arterial calcification and not lumen stenosis is highly correlated with atherosclerotic plaque burden in humans: a histologic study of 723 coronary artery segments using nondecalcifying methodology.J. Am. Coll. Cardiol. 1998; 31: 126-133Abstract Full Text Full Text PDF PubMed Scopus (861) Google Scholar], one could hypothesize that treatment with statins could also decrease the progression of plaque calcium. However, large prospective studies failed to show decreased progression of coronary calcium in subjects treated with statins [[6]McEvoy J.W. Blaha M.J. DeFilippis A.P. Budoff M.J. Nasir K. Blumenthal R.S. et al.Coronary artery calcium progression: an important clinical measurement? A review of published reports.J. Am. Coll. Cardiol. 2010; 56: 1613-1622Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar].Two recently reported IVUS studies (SATURN and IBIS 4) shed light on the role of statins on plaque calcification and stability [7Puri R. Nicholls S.J. Shao M. Kataoka Y. Uno K. Kapadia S.R. et al.Impact of statins on serial coronary calcification during atheroma progression and regression.J. Am. Coll. Cardiol. 2015; 65: 1273-1282Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar, 8Räber L. Taniwaki M. Zaugg S. Kelbæk H. Roffi M. Holmvang L. et al.Effect of high-intensity statin therapy on atherosclerosis in non-infarct-related coronary arteries (IBIS-4): a serial intravascular ultrasonography study.Eur. Heart J. 2015; 36: 490-500Crossref PubMed Scopus (120) Google Scholar]. Puri et al. performed an analysis of serial IVUS data from 8 large multicenter clinical trials [[7]Puri R. Nicholls S.J. Shao M. Kataoka Y. Uno K. Kapadia S.R. et al.Impact of statins on serial coronary calcification during atheroma progression and regression.J. Am. Coll. Cardiol. 2015; 65: 1273-1282Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar]. The use of high-intensity statin was associated with plaque regression during 18- to 24-months of follow-up. Concurrently, the amount of coronary calcium increased in all patients irrespective of statin use. The greatest increase in calcium was observed in patients treated with high-intensity statin and coincided with significant plaque regression. In contrast, statin-naive patients demonstrated the smallest increase in plaque calcification over time, despite profound atheroma progression. In another serial IVUS study, Raber et al. demonstrated regression of coronary plaque in 82 patients who received high-intensity statin therapy after ST segment elevation myocardial infarction [[8]Räber L. Taniwaki M. Zaugg S. Kelbæk H. Roffi M. Holmvang L. et al.Effect of high-intensity statin therapy on atherosclerosis in non-infarct-related coronary arteries (IBIS-4): a serial intravascular ultrasonography study.Eur. Heart J. 2015; 36: 490-500Crossref PubMed Scopus (120) Google Scholar]. Using virtual histology IVUS imaging, the authors observed overall reduction of percent atheroma volume, increase in percent calcified plaque volume and decrease of percent fibrous plaque volume. The authors also found small, but significant, decrease in necrotic core volume with high-intensity statins. Collectively, these two serial IVUS studies suggested that statins increase the calcium content of coronary atherosclerotic plaque.In the current issue of Atherosclerosis, Auschler et al. reported the results of serial coronary computed tomography angiography (CTA) imaging in 96 patients after acute myocardial infarction [[9]Auscher S. Heinsen L. Nieman K. Vinther K.H. Løngstrup B. Møller J.E. et al.Effects of intensive lipid-lowering therapy on coronary plaques composition in patients with acute myocardial infarction: assessment with serial coronary CT angiography.Atherosclerosis. 2015; 241: 579-587Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar]. This is an interesting and innovative study that complements the previous reports that employed invasive imaging with IVUS. Coronary CTA can detect coronary atherosclerosis and provide quantitative and qualitative assessment of plaque in the entire coronary tree [[10]Maurovich-Horvat P. Ferencik M. Voros S. Merkely B. Hoffmann U. Comprehensive plaque assessment by coronary CT angiography.Nat. Rev. Cardiol. 2014; PubMed Google Scholar]. While the feasibility of serial plaque assessment using coronary CTA was demonstrated previously, there have been only small serial follow-up studies with limited assessment of selected plaques [11Uehara M. Funabashi N. Mikami Y. Shiina Y. Nakamura K. Komuro I. Quantitative effect of atorvastatin on size and content of non-calcified plaques of coronary arteries 1 year after atorvastatin treatment by multislice computed tomography.Int. J. Cardiol. 2008; 130: 269-275Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 12Soeda T. Uemura S. Okayama S. Kawakami R. Sugawara Y. Nakagawa H. et al.Intensive lipid-lowering therapy with rosuvastatin stabilizes lipid-rich coronary plaques.Circ. J. 2011; 75: 2621-2627Crossref PubMed Scopus (25) Google Scholar, 13Burgstahler C. Reimann A. Beck T. Kuettner A. Baumann D. Heuschmid M. et al.Influence of a lipid-lowering therapy on calcified and noncalcified coronary plaques monitored by multislice detector computed tomography: results of the New Age II Pilot Study.Invest. Radiol. 2007; 42: 189-195Crossref PubMed Scopus (96) Google Scholar, 14Lehman S.J. Schlett C.L. Bamberg F. Lee H. Donnelly P. Shturman L. et al.Assessment of coronary plaque progression in coronary computed tomography angiography using a semiquantitative score.JACC Cardiovasc Imaging. 2009; 2: 1262-1270Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar]. The study reported in this issue of Atherosclerosis included the largest population of patients who underwent serial coronary CTA imaging. The authors performed a single-center randomized trial of high-intensity vs. standard-dose statin therapy and measured changes of coronary plaque volume and composition after 12 months of follow-up. The investigators fully leveraged the advantages of coronary CTA by performing the plaque analysis in the entire coronary tree, including total plaque volume (measured both as absolute and percent plaque volume) and by analyzing plaque constituents based on CT attenuation characteristics. Despite the fact that coronary plaque volume progressed similarly in both study groups, there was a significant difference in plaque composition changes. The volume of dense coronary calcium increased significantly (by 23%) in the high-intensity statin group, but not in the standard statin group. Intriguingly, this progression rate is consistent with previously reported annual rate of coronary artery calcium progression by 20–30% [[6]McEvoy J.W. Blaha M.J. DeFilippis A.P. Budoff M.J. Nasir K. Blumenthal R.S. et al.Coronary artery calcium progression: an important clinical measurement? A review of published reports.J. Am. Coll. Cardiol. 2010; 56: 1613-1622Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar]. In contrast to calcium, low CT attenuation plaque volume (i.e. lipid pool volume) increased similarly in both groups. Of note, there was no change in the prevalence of high-risk plaque features, such as positive remodeling, low CT attenuation plaque or spotty calcium. However, these observations were limited by the low prevalence of high-risk plaque features.The strength of the reported investigation lays on the non-invasive method of plaque assessment and ability to assess the entire coronary tree in contrast to IVUS which is typically performed only in the proximal segments of single coronary arteries. The authors reported an excellent interobserver and intraobserver variability of coronary plaque measurements with coronary CTA. The analysis was facilitated by the use of semi-automated coronary plaque assessment software, which has been shown to produce reliable plaque quantification and characterization compared to IVUS [[15]de Graaf M.A. Broersen A. Kitslaar P.H. Roos C.J. Dijkstra J. Lelieveldt B.P.F. et al.Automatic quantification and characterization of coronary atherosclerosis with computed tomography coronary angiography: cross-correlation with intravascular ultrasound virtual histology.Int. J. Cardiovasc. Imaging. 2013; 29: 1177-1190Crossref PubMed Scopus (141) Google Scholar].There were several limitations within this work. The study was performed in a single center with high quality coronary CTA data. Despite the use of the semi-automated software, the analysis of coronary plaque in the entire coronary tree still required substantial amount of time. In contrast to IVUS studies, the coronary CTA study failed to demonstrate the reduction of plaque volume with high-intensity statin therapy in part due to the shorter follow-up and the lower spatial resolution of CT that precluded the detection of small plaque volume changes.Corroborative data on the role of progressive coronary atheroma calcification in the natural history of atherosclerosis came from histopathology studies, which showed that micro-calcifications within early plaque lipid pools coalesce into speckles and fragments and eventually form dense calcified sheets during atheroma progression [[16]Otsuka F. Sakakura K. Yahagi K. Joner M. Virmani R. Has our understanding of calcification in human coronary atherosclerosis progressed?.Arterioscler. Thromb. Vasc. Biol. 2014; 34: 724-736Crossref PubMed Scopus (290) Google Scholar]. Calcium content is higher in advanced fibro-calcific plaques and healed plaque ruptures, whereas plaques associated with vulnerability (i.e. thin-cap fibroatheromata and ruptured plaques) have spotty calcified areas and less diffuse calcium, suggesting a dynamic role of calcium in plaque evolution and stability [[16]Otsuka F. Sakakura K. Yahagi K. Joner M. Virmani R. Has our understanding of calcification in human coronary atherosclerosis progressed?.Arterioscler. Thromb. Vasc. Biol. 2014; 34: 724-736Crossref PubMed Scopus (290) Google Scholar].In conclusion, the results of studies with IVUS and coronary CTA consistently showed the increase of densely calcified plaque with high-intensity statin treatment. That increase in plaque calcium may set the pathobiologic basis for improved clinical outcomes and thus may represent a plaque-stabilizing effect of statins beyond the effect on atherosclerotic plaque progression (Fig. 1). Thus, paradoxically while having a large amount of coronary artery calcium is a strong predictor of increased risk for cardiovascular events [[17]Detrano R. Guerci A.D. Carr J.J. Bild D.E. Burke G. Folsom A.R. et al.Coronary calcium as a predictor of coronary events in four racial or ethnic groups.N. Engl. J. Med. 2008; 358: 1336-1345Crossref PubMed Scopus (2081) Google Scholar], increase of coronary plaque calcium over time observed with statin treatment may be associated with more stable plaque characteristics and possibly improved outcomes. This concept is supported by a recent study which showed that the presence of dense calcified plaque can be associated with lower risk of cardiovascular events as compared to the presence of calcified plaque with low CT density [[18]Criqui M.H. Denenberg J.O. Ix J.H. McClelland R.L. Wassel C.L. Rifkin D.E. et al.Calcium density of coronary artery plaque and risk of Incident cardiovascular events.JAMA. 2014; 311: 271-278Crossref PubMed Scopus (373) Google Scholar]. In the future, changes in coronary plaque composition with focus on the increase of densely calcified plaque may become a surrogate imaging endpoint in exploring novel anti-atherosclerotic therapies. Further improvements in the reproducibility and feasibility of non-invasive coronary plaque quantification and characterization are necessary prior to implementation of non-invasive plaque imaging in clinical trials.Funding sourcesThis work was supported by a grant from American Heart Association Fellow to Faculty Award 13FTF16450001 to MF and a grant from Behrakis Foundation, Boston, MA to YSC. The beneficial effect of statins on slowing coronary atherosclerotic plaque progression or even leading to plaque regression has been clearly established with intravascular ultrasound (IVUS) imaging [1Nissen S.E. Nicholls S.J. Sipahi I. Libby P. Raichlen J.S. Ballantyne C.M. et al.Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: the ASTEROID trial.JAMA. 2006; 295: 1556-1565Crossref PubMed Scopus (1713) Google Scholar, 2Nicholls S.J. Ballantyne C.M. Barter P.J. Chapman M.J. Erbel R.M. Libby P. et al.Effect of two intensive statin regimens on progression of coronary disease.N. Engl. J. Med. 2011; 365: 2078-2087Crossref PubMed Scopus (607) Google Scholar]. In fact, the effect of statins on coronary plaque progression/regression appears to be dose-dependent with the larger effect observed with high-intensity statin treatment. Coronary calcium is an integral part of atherosclerotic process with spotty calcification being associated with inflammation and plaque vulnerability and dense calcium associated with more stable plaque phenotypes [3Libby P. How does lipid lowering prevent coronary events? New insights from human imaging trials.Eur. Heart J. 2015; 36: 472-474Crossref PubMed Scopus (37) Google Scholar, 4Joshi N.V. Vesey A.T. Williams M.C. Shah A.S.V. Calvert P.A. Craighead F.H.M. et al.18F-fluoride positron emission tomography for identification of ruptured and high-risk coronary atherosclerotic plaques: a prospective clinical trial.Lancet. 2014; 383: 705-713Abstract Full Text Full Text PDF PubMed Scopus (652) Google Scholar]. Given that the burden of calcified atherosclerotic plaque closely correlates with overall coronary plaque burden as assessed ex vivo by histopathology [[5]Sangiorgi G. Rumberger J.A. Severson A. Edwards W.D. Gregoire J. Fitzpatrick L.A. et al.Arterial calcification and not lumen stenosis is highly correlated with atherosclerotic plaque burden in humans: a histologic study of 723 coronary artery segments using nondecalcifying methodology.J. Am. Coll. Cardiol. 1998; 31: 126-133Abstract Full Text Full Text PDF PubMed Scopus (861) Google Scholar], one could hypothesize that treatment with statins could also decrease the progression of plaque calcium. However, large prospective studies failed to show decreased progression of coronary calcium in subjects treated with statins [[6]McEvoy J.W. Blaha M.J. DeFilippis A.P. Budoff M.J. Nasir K. Blumenthal R.S. et al.Coronary artery calcium progression: an important clinical measurement? A review of published reports.J. Am. Coll. Cardiol. 2010; 56: 1613-1622Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar]. Two recently reported IVUS studies (SATURN and IBIS 4) shed light on the role of statins on plaque calcification and stability [7Puri R. Nicholls S.J. Shao M. Kataoka Y. Uno K. Kapadia S.R. et al.Impact of statins on serial coronary calcification during atheroma progression and regression.J. Am. Coll. Cardiol. 2015; 65: 1273-1282Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar, 8Räber L. Taniwaki M. Zaugg S. Kelbæk H. Roffi M. Holmvang L. et al.Effect of high-intensity statin therapy on atherosclerosis in non-infarct-related coronary arteries (IBIS-4): a serial intravascular ultrasonography study.Eur. Heart J. 2015; 36: 490-500Crossref PubMed Scopus (120) Google Scholar]. Puri et al. performed an analysis of serial IVUS data from 8 large multicenter clinical trials [[7]Puri R. Nicholls S.J. Shao M. Kataoka Y. Uno K. Kapadia S.R. et al.Impact of statins on serial coronary calcification during atheroma progression and regression.J. Am. Coll. Cardiol. 2015; 65: 1273-1282Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar]. The use of high-intensity statin was associated with plaque regression during 18- to 24-months of follow-up. Concurrently, the amount of coronary calcium increased in all patients irrespective of statin use. The greatest increase in calcium was observed in patients treated with high-intensity statin and coincided with significant plaque regression. In contrast, statin-naive patients demonstrated the smallest increase in plaque calcification over time, despite profound atheroma progression. In another serial IVUS study, Raber et al. demonstrated regression of coronary plaque in 82 patients who received high-intensity statin therapy after ST segment elevation myocardial infarction [[8]Räber L. Taniwaki M. Zaugg S. Kelbæk H. Roffi M. Holmvang L. et al.Effect of high-intensity statin therapy on atherosclerosis in non-infarct-related coronary arteries (IBIS-4): a serial intravascular ultrasonography study.Eur. Heart J. 2015; 36: 490-500Crossref PubMed Scopus (120) Google Scholar]. Using virtual histology IVUS imaging, the authors observed overall reduction of percent atheroma volume, increase in percent calcified plaque volume and decrease of percent fibrous plaque volume. The authors also found small, but significant, decrease in necrotic core volume with high-intensity statins. Collectively, these two serial IVUS studies suggested that statins increase the calcium content of coronary atherosclerotic plaque. In the current issue of Atherosclerosis, Auschler et al. reported the results of serial coronary computed tomography angiography (CTA) imaging in 96 patients after acute myocardial infarction [[9]Auscher S. Heinsen L. Nieman K. Vinther K.H. Løngstrup B. Møller J.E. et al.Effects of intensive lipid-lowering therapy on coronary plaques composition in patients with acute myocardial infarction: assessment with serial coronary CT angiography.Atherosclerosis. 2015; 241: 579-587Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar]. This is an interesting and innovative study that complements the previous reports that employed invasive imaging with IVUS. Coronary CTA can detect coronary atherosclerosis and provide quantitative and qualitative assessment of plaque in the entire coronary tree [[10]Maurovich-Horvat P. Ferencik M. Voros S. Merkely B. Hoffmann U. Comprehensive plaque assessment by coronary CT angiography.Nat. Rev. Cardiol. 2014; PubMed Google Scholar]. While the feasibility of serial plaque assessment using coronary CTA was demonstrated previously, there have been only small serial follow-up studies with limited assessment of selected plaques [11Uehara M. Funabashi N. Mikami Y. Shiina Y. Nakamura K. Komuro I. Quantitative effect of atorvastatin on size and content of non-calcified plaques of coronary arteries 1 year after atorvastatin treatment by multislice computed tomography.Int. J. Cardiol. 2008; 130: 269-275Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 12Soeda T. Uemura S. Okayama S. Kawakami R. Sugawara Y. Nakagawa H. et al.Intensive lipid-lowering therapy with rosuvastatin stabilizes lipid-rich coronary plaques.Circ. J. 2011; 75: 2621-2627Crossref PubMed Scopus (25) Google Scholar, 13Burgstahler C. Reimann A. Beck T. Kuettner A. Baumann D. Heuschmid M. et al.Influence of a lipid-lowering therapy on calcified and noncalcified coronary plaques monitored by multislice detector computed tomography: results of the New Age II Pilot Study.Invest. Radiol. 2007; 42: 189-195Crossref PubMed Scopus (96) Google Scholar, 14Lehman S.J. Schlett C.L. Bamberg F. Lee H. Donnelly P. Shturman L. et al.Assessment of coronary plaque progression in coronary computed tomography angiography using a semiquantitative score.JACC Cardiovasc Imaging. 2009; 2: 1262-1270Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar]. The study reported in this issue of Atherosclerosis included the largest population of patients who underwent serial coronary CTA imaging. The authors performed a single-center randomized trial of high-intensity vs. standard-dose statin therapy and measured changes of coronary plaque volume and composition after 12 months of follow-up. The investigators fully leveraged the advantages of coronary CTA by performing the plaque analysis in the entire coronary tree, including total plaque volume (measured both as absolute and percent plaque volume) and by analyzing plaque constituents based on CT attenuation characteristics. Despite the fact that coronary plaque volume progressed similarly in both study groups, there was a significant difference in plaque composition changes. The volume of dense coronary calcium increased significantly (by 23%) in the high-intensity statin group, but not in the standard statin group. Intriguingly, this progression rate is consistent with previously reported annual rate of coronary artery calcium progression by 20–30% [[6]McEvoy J.W. Blaha M.J. DeFilippis A.P. Budoff M.J. Nasir K. Blumenthal R.S. et al.Coronary artery calcium progression: an important clinical measurement? A review of published reports.J. Am. Coll. Cardiol. 2010; 56: 1613-1622Abstract Full Text Full Text PDF PubMed Scopus (189) Google Scholar]. In contrast to calcium, low CT attenuation plaque volume (i.e. lipid pool volume) increased similarly in both groups. Of note, there was no change in the prevalence of high-risk plaque features, such as positive remodeling, low CT attenuation plaque or spotty calcium. However, these observations were limited by the low prevalence of high-risk plaque features. The strength of the reported investigation lays on the non-invasive method of plaque assessment and ability to assess the entire coronary tree in contrast to IVUS which is typically performed only in the proximal segments of single coronary arteries. The authors reported an excellent interobserver and intraobserver variability of coronary plaque measurements with coronary CTA. The analysis was facilitated by the use of semi-automated coronary plaque assessment software, which has been shown to produce reliable plaque quantification and characterization compared to IVUS [[15]de Graaf M.A. Broersen A. Kitslaar P.H. Roos C.J. Dijkstra J. Lelieveldt B.P.F. et al.Automatic quantification and characterization of coronary atherosclerosis with computed tomography coronary angiography: cross-correlation with intravascular ultrasound virtual histology.Int. J. Cardiovasc. Imaging. 2013; 29: 1177-1190Crossref PubMed Scopus (141) Google Scholar]. There were several limitations within this work. The study was performed in a single center with high quality coronary CTA data. Despite the use of the semi-automated software, the analysis of coronary plaque in the entire coronary tree still required substantial amount of time. In contrast to IVUS studies, the coronary CTA study failed to demonstrate the reduction of plaque volume with high-intensity statin therapy in part due to the shorter follow-up and the lower spatial resolution of CT that precluded the detection of small plaque volume changes. Corroborative data on the role of progressive coronary atheroma calcification in the natural history of atherosclerosis came from histopathology studies, which showed that micro-calcifications within early plaque lipid pools coalesce into speckles and fragments and eventually form dense calcified sheets during atheroma progression [[16]Otsuka F. Sakakura K. Yahagi K. Joner M. Virmani R. Has our understanding of calcification in human coronary atherosclerosis progressed?.Arterioscler. Thromb. Vasc. Biol. 2014; 34: 724-736Crossref PubMed Scopus (290) Google Scholar]. Calcium content is higher in advanced fibro-calcific plaques and healed plaque ruptures, whereas plaques associated with vulnerability (i.e. thin-cap fibroatheromata and ruptured plaques) have spotty calcified areas and less diffuse calcium, suggesting a dynamic role of calcium in plaque evolution and stability [[16]Otsuka F. Sakakura K. Yahagi K. Joner M. Virmani R. Has our understanding of calcification in human coronary atherosclerosis progressed?.Arterioscler. Thromb. Vasc. Biol. 2014; 34: 724-736Crossref PubMed Scopus (290) Google Scholar]. In conclusion, the results of studies with IVUS and coronary CTA consistently showed the increase of densely calcified plaque with high-intensity statin treatment. That increase in plaque calcium may set the pathobiologic basis for improved clinical outcomes and thus may represent a plaque-stabilizing effect of statins beyond the effect on atherosclerotic plaque progression (Fig. 1). Thus, paradoxically while having a large amount of coronary artery calcium is a strong predictor of increased risk for cardiovascular events [[17]Detrano R. Guerci A.D. Carr J.J. Bild D.E. Burke G. Folsom A.R. et al.Coronary calcium as a predictor of coronary events in four racial or ethnic groups.N. Engl. J. Med. 2008; 358: 1336-1345Crossref PubMed Scopus (2081) Google Scholar], increase of coronary plaque calcium over time observed with statin treatment may be associated with more stable plaque characteristics and possibly improved outcomes. This concept is supported by a recent study which showed that the presence of dense calcified plaque can be associated with lower risk of cardiovascular events as compared to the presence of calcified plaque with low CT density [[18]Criqui M.H. Denenberg J.O. Ix J.H. McClelland R.L. Wassel C.L. Rifkin D.E. et al.Calcium density of coronary artery plaque and risk of Incident cardiovascular events.JAMA. 2014; 311: 271-278Crossref PubMed Scopus (373) Google Scholar]. In the future, changes in coronary plaque composition with focus on the increase of densely calcified plaque may become a surrogate imaging endpoint in exploring novel anti-atherosclerotic therapies. Further improvements in the reproducibility and feasibility of non-invasive coronary plaque quantification and characterization are necessary prior to implementation of non-invasive plaque imaging in clinical trials. Funding sourcesThis work was supported by a grant from American Heart Association Fellow to Faculty Award 13FTF16450001 to MF and a grant from Behrakis Foundation, Boston, MA to YSC. This work was supported by a grant from American Heart Association Fellow to Faculty Award 13FTF16450001 to MF and a grant from Behrakis Foundation, Boston, MA to YSC." @default.
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• W1538648639 title "Statins and the coronary plaque calcium “paradox”: Insights from non-invasive and invasive imaging" @default.
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