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To characterize sex differences in coronary atherosclerosis in patients with chest pain and zero CACS. Patients evaluated for suspected CAD at Turku University Hospital 2006\u20132016 with zero CACS were included. In addition to clinical reading, artificial intelligence-based quantitative analysis (AI-QCT) of coronary computed tomography angiography (CTA) images was performed. Long-term clinical outcome of myocardial infarction, unstable angina or death was analyzed. Out of 2,216 patients with CTA results, 606 had zero CACS (156 men and 450 women, median age 54 vs. 61). Around 5% of men and 2% of women with zero CACS had obstructive CAD, with comparable findings on clinical CTA and AI-QCT. Non-obstructive disease was found in higher proportion on AI-QCT (88.5% of men and 85.6% of women) than on clinical reading (16.7% of men and 11.6% of women). Non-calcified plaques dominated, but small calcifications were not uncommon. Low-density plaques increased with the severity of CAD. After a median follow-up of 7.3 years, only 3 men and 14 women experienced clinical events, yielding an annual event rate of 0.26% in men and 0.43% in women. In patients with suspected CAD and zero CACS obstructive CAD is detected in around 5% of men and 2% of women. Non-obstructive CAD is detected in a vast majority with AI-QCT. Despite this, long-term clinical outcome is generally very good.<\/jats:p>\n                  <jats:p>\n                    <jats:bold>Graphical abstract\u00a0<\/jats:bold>\n                  <\/jats:p>\n                  <jats:p>Central illustration:<\/jats:p>","DOI":"10.1007\/s10554-026-03623-x","type":"journal-article","created":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T02:56:45Z","timestamp":1768791405000},"page":"531-541","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Coronary atherosclerosis on AI-based plaque analysis in patients with chest pain and calcium score zero"],"prefix":"10.1007","volume":"42","author":[{"given":"David","family":"Molnar","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juhani","family":"Knuuti","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeroen J.","family":"Bax","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antti","family":"Saraste","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Teemu","family":"Maaniitty","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,1,19]]},"reference":[{"issue":"4","key":"3623_CR1","doi-asserted-by":"publisher","first-page":"827","DOI":"10.1016\/0735-1097(90)90282-T","volume":"15","author":"AS Agatston","year":"1990","unstructured":"Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R (1990) Quantification of coronary artery calcium using ultrafast computed tomography. 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Cleerly, Inc. performed the image analysis without costs and provided an unrestricted research grant for the University of Turku. Dr. Molnar\u2019s work has been co-funded by the European Union\u2019s Horizon Europe Framework program for research and innovation 2021-2027 under the Marie Slodowska-Curie grant agreement No. 101126611, the Swedish Medical Society, the Swedish Heart-Lung Foundation, the Swedish Heart Union and the Gothenburg Medical Society. Dr. Knuuti received consultancy fees from GE Healthcare and Synektik and speaker fees from Bayer, Lundbeck, Boehringer-Ingelheim, Pfizer and Siemens, outside of the submitted work. Dr. Bax received speaker fees from Abbott, outside of the submitted work. Dr. Saraste received consultancy fees from Astra Zeneca, Novo Nordisk and Pfizer, and speaker fees from Abbott, Astra Zeneca, BMS, Janssen, and Pfizer outside of the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}]}}