Sex differences in detection of acute coronary syndrome culprit lesion using conventional and AI-enhanced coronary CT angiography

European Heart Journal - Cardiovascular Imaging

6 October 2026

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Abstract

AbstractAims

Acute coronary syndrome (ACS) exhibits marked sex-related differences in clinical presentation and underlying pathophysiology. However, whether these differences translate into variations in culprit lesion prediction remains unclear. We investigated the sex-specific performance of conventional coronary computed tomography angiography (CCTA) and artificial intelligence-enabled quantitative coronary plaque and haemodynamic assessment (AI-QCPHA) for ACS culprit detection.

Methods and results

In this sub-study of the EMERALD II trial (NCT03591328), patients with ACS who underwent CCTA 1 month to 3 years prior to the event were analysed. Culprit and non-culprit lesions were defined by invasive coronary angiography at the time of ACS. Diagnostic performance of obstructive stenosis (Coronary Artery Disease-Reporting and Data System ≥ 3) and high-risk plaque (HRP) criteria was compared between women and men. Information gain-based feature selection identified sex-specific AI-QCPHA best predictors across five feature clusters, and their incremental predictive value was evaluated using receiver operating characteristics reported as area under the curve (AUC). A total of 351 patients (90 women, 261 men) with 2451 lesions were included. Conventional CCTA performed similarly across sexes for obstructive stenosis, whereas HRP differed by sex. AI-QCPHA identified the same best features for ACS culprit prediction in both sexes, and integration of these features improved discriminatory performance beyond conventional CCTA (women AUC 0.84 vs. 0.78, P = 0.002; men 0.82 vs. 0.75, P < 0.001). Among individual predictors, delta fractional flow reserve from coronary computed tomography angiography yielded the highest discriminatory performance in both women and men.

Conclusion

AI-QCPHA enhances culprit lesion prediction in obstructive ACS beyond conventional CCTA in both sexes, supporting its potential role for improved culprit lesion discrimination.