Risk assessment of acute pulmonary embolism utilizing coronary artery calcifications in patients that have undergone CT pulmonary angiography and transthoracic echocardiography

Prognostic Value of Incidental Coronary Artery Calcifications in Computed Tomography Pulmonary Angiography for Suspected Pulmonary Embolism

Computed tomography (CT) has emerged as a noninvasive method to identify coronary artery calcifications (CAC). We sought to investigate the association between opportunistic visual CAC evaluation in patients without known coronary artery disease who underwent CT pulmonary angiography (CTPA) for pulmonary embolism (PE) suspicion, and cardiovascular prognosis. We analyzed data of patients who underwent CTPA for suspected PE in 2017 at CHU Dupuytren, Limoges, France. Patients were categorized into 4 groups according to a simple visual ordinal score to assess the extent and severity of CAC on a whole-patient basis: none (grade 0), mild (grade 1), moderate (grade 2), and severe (grade 3). The primary outcome was a composite of cardiovascular mortality, myocardial infarction (MI), or coronary revascularization. The secondary outcomes were all-cause mortality, and an extended composite outcome including cardiovascular mortality, MI, coronary revascularization, ischemic stroke, ischemic peripheral events, and hospitalization for heart failure. A total of 414 patients (mean age 69.7 ± 14.3 years, 42% men, 18.1% PE) were included in the analysis and subdivided according to CAC categories as follows: grade 0 (n = 123; 29.7%), grade 1 (n = 133; 32.1%), grade 2 (n = 79; 19.1%) and grade 3 (n = 79; 19.1%). The mean follow-up was 3.5 ± 2.4 years. After adjustment, the presence of CAC grade 2 to 3 CAC independently predicted the primary outcome (hazard ratio [HR] = 5.30, 95% CI 2.56 to 10.98, p <0.001). CAC grade 2 to 3 were also independent predictors for all-cause mortality (HR = 1.52, 95% CI 1.10 to 2.11, p = 0.011); and the extended composite event (HR = 1.82, 95% CI 1.13 to 2.95, p = 0.014). In conclusion, the opportunistic assessment of CAC in CTPA for suspected PE could provide important mid-term prognostic information, independently from the PE findings.

Adjusting Atrial Size Parameters for Body Surface Area: Does it Affect the Association With Pulmonary Embolism-related Adverse Events?

PURPOSE

Small left atrial (LA) volume was recently reported to be one of the best predictors of acute pulmonary embolism (PE)-related adverse events (AE). There is currently no data available regarding the impact that body surface area (BSA)-indexing of atrial measurements has on the association with PE-related adverse events. Our aim is to assess the impact of indexing atrial measurements to BSA on the association between computed tomography (CT) atrial measurements and AE.

MATERIALS AND METHODS

Retrospective study (IRB: 2015P000425). A database of hospitalized patients with acute PE diagnosed on CT pulmonary angiography (CTPA) between May 2007 and December 2014 was reviewed. Right and left atrial volume, largest axial area, and axial diameters were measured. Patients undergo both echocardiographies (from which the BSA was extracted) and CTPAs within 48 hours of the procedure. The patient's body weight was measured during each admission. LA measurements were correlated to AE (defined as the need for advanced therapy or PE-related mortality at 30 days) before and after indexing for BSA. The area under the ROC curve was calculated to determine the predictive value of the atrial measurements in predicting AE.

RESULTS

The study included 490 acute PE patients; 62 (12.7%) had AE. There was a significant association of reduced BSA-indexed and non-indexed LA volume (both <0.001), area (<0.001 and 0.001, respectively), and short-axis diameters (both <0.001), and their respective RA/LA ratios (all <0.001) with AE. The AUC values were similar for BSA-indexed and non-indexed LA volume, diameters, and area with LA volume measurements being the best predictor of adverse outcomes (BSA-indexed AUC=0.68 and non-indexed AUC=0.66), followed by non-indexed LA short-axis diameter (indexed AUC=0.65, non-indexed AUC=0.64), and LA area (indexed AUC=0.64, non-indexed AUC=0.63).

CONCLUSION

Adjusting for BSA does not substantially affect the predictive ability of atrial measurements on 30-day PE-related adverse events, and therefore, this adjustment is not necessary in clinical practice. While LA volume is the better predictor of AE, LA short-axis diameter has a similar predictive value and is more practical to perform clinically.

Prevalence and clinical implications of coronary artery calcium scoring on non-gated thoracic computed tomography: a systematic review and meta-analysis

OBJECTIVES

Coronary artery calcifications (CACs) indicate the presence of coronary artery disease. CAC can be found on thoracic computed tomography (CT) conducted for non-cardiac reasons. This systematic review and meta-analysis of non-gated thoracic CT aims to assess the clinical impact and prevalence of CAC.

METHODS

Online databases were searched for articles assessing prevalence, demographic characteristics, accuracy and prognosis of incidental CAC on non-gated thoracic CT. Meta-analysis was performed using a random effects model.

RESULTS

A total of 108 studies (113,406 patients) were included (38% female). Prevalence of CAC ranged from 2.7 to 100% (pooled prevalence 52%, 95% confidence interval [CI] 46-58%). Patients with CAC were older (pooled standardised mean difference 0.88, 95% CI 0.65-1.11, p < 0.001), and more likely to be male (pooled odds ratio [OR] 1.95, 95% CI 1.55-2.45, p < 0.001), with diabetes (pooled OR 2.63, 95% CI 1.95-3.54, p < 0.001), hypercholesterolaemia (pooled OR 2.28, 95% CI 1.33-3.93, p < 0.01) and hypertension (pooled OR 3.89, 95% CI 2.26-6.70, p < 0.001), but not higher body mass index or smoking. Non-gated CT assessment of CAC had excellent agreement with electrocardiogram-gated CT (pooled correlation coefficient 0.96, 95% CI 0.92-0.98, p < 0.001). In 51,582 patients, followed-up for 51.6 ± 27.4 months, patients with CAC had increased all cause mortality (pooled relative risk [RR] 2.13, 95% CI 1.57-2.90, p = 0.004) and major adverse cardiovascular events (pooled RR 2.91, 95% CI 2.26-3.93, p < 0.001). When CAC was present on CT, it was reported in between 18.6% and 93% of reports.

CONCLUSION

CAC is a common, but underreported, finding on non-gated CT with important prognostic implications.

CLINICAL RELEVANCE STATEMENT

Coronary artery calcium is an important prognostic indicator of cardiovascular disease. It can be assessed on non-gated thoracic CT and is a commonly underreported finding. This represents a significant population where there is a potential missed opportunity for lifestyle modification recommendations and preventative therapies. This study aims to highlight the importance of reporting incidental coronary artery calcium on non-gated thoracic CT.

KEY POINTS

• Coronary artery calcification is a common finding on non-gated thoracic CT and can be reliably identified compared to gated-CT. • Coronary artery calcification on thoracic CT is associated with an increased risk of all cause mortality and major adverse cardiovascsular events. • Coronary artery calcification is frequently not reported on non-gated thoracic CT.

Value of computed tomography pulmonary angiography measurements in predicting 30-day mortality among patients with acute pulmonary embolism

Purpose

Late diagnosis is associated with high mortality rates in acute pulmonary embolism (PE), so early diagnosis and risk assessment are crucial. We aim to evaluate computed tomography pulmonary angiography measurements to identify relationships with 30-day mortality in patients with pulmonary embolism. This study investigated the utility of computed tomography pulmonary angiography (CTPA) measures in determining 30-day PE-related mortality and identified various echocardiographic, demographic, and clinical variables that were independently associated with short-term mortality in patients with acute PE.

Material and methods

This retrospective study examined data from July 2018 to April 2023. A total of 118 patients were included in the study. Clinical and demographic characteristics, laboratory findings, echocardiographic data, and CTPA images were retrieved from the electronic database and patient charts.

Results

The rate of 30-day mortality was 14.41%. Deceased patients were significantly older than survivors (73.53 ± 14.17 vs. 60.23 ± 17.49 years; p = 0.004), but the sex distribution was similar. In multivariable logistic regression, having received radiotherapy for malignancy, high pulmonary artery obstruction index % (> 46.2), high left pulmonary artery diameter (> 23.9 mm), and high coronary artery calcification score (> 5.5) were independently associated with mortality.

Conclusions

These results reveal specific parameters that can assist acute PE management by enabling the identification of critical events. Despite promising results in predicting short-term mortality in acute PE, further prospective cohort studies are needed to confirm the results of the present study.

Predictive Value of Coronary Artery Calcium in Patients Receiving Computed Tomography Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department

PURPOSE

Coronary artery calcium (CAC) is a frequent incidental finding on computed tomography pulmonary angiogram (CTPA) in the evaluation of pulmonary embolism (PE) in the emergency department (ED); however, its prognostic value is unclear. In this study, we interrogate the prognostic value of CAC identified on CTPA in predicting adverse outcomes in the evaluation of PE in the ED.

MATERIALS AND METHODS

In this retrospective cohort study, we identified 610 patients presenting to the ED in 2013 and evaluated with CTPA for suspected PE. Ordinal CAC scores were evaluated as absent (0), mild (1), moderate (2), or severe (3) in each of the 4 main coronary arteries. Composite CAC scores were subsequently compared against adverse clinical outcomes, defined as intensive care unit admission, hospital stay longer than 72 hours, or death during hospital course or at 6-month follow-up, using univariate and multivariate logistic regression analyses. Relevant exclusion criteria included a history of cardiovascular disease.

RESULTS

In all, 365 patients met the inclusion criteria (231 women, mean age 56±16 y) with 132 patients (36%) having some degree of CAC and 16 (4%) having severe CAC. Known malignancy was present in 151 (41%) patients and composite adverse clinical outcomes were observed in 98 patients (32%). Age, presence of acute PE, malignancy, and presence of CAC were significant predictors of adverse outcomes on both univariate and multivariate analyses. CAC was not an independent predictor of short-term adverse outcomes on multivariate analysis ( P =0.06) when all patients were considered. However, when patients with known malignancy were excluded, CAC was an independent predictor of short-term adverse outcomes (odds ratio=2.5, confidence interval=1.1-5.5, P =0.03) independent of age and presence of PE.

CONCLUSION

The presence of CAC on CT PA was predictive of adverse outcomes in patients without known cardiac disease presenting to the ED with suspected PE.

Evaluating cardiopulmonary function following acute pulmonary embolism

INTRODUCTION

Pulmonary embolism is a common cause of cardiopulmonary mortality and morbidity worldwide. Survivors of acute pulmonary embolism may experience dyspnea, report reduced exercise capacity, or develop overt pulmonary hypertension. Clinicians must be alert for these phenomena and appreciate the modalities and investigations available for evaluation.

AREAS COVERED

In this review, the current understanding of available contemporary imaging and physiologic modalities is discussed, based on available literature and professional society guidelines. The purpose of the review is to provide clinicians with an overview of these modalities, their strengths and disadvantages, and how and when these investigations can support the clinical work-up of patients post-pulmonary embolism.

EXPERT OPINION

Echocardiography is a first test in symptomatic patients post-pulmonary embolism, with ventilation/perfusion scanning vital to determination of whether there is chronic residual emboli. The role of computed tomography and magnetic resonance in assessing the pulmonary arterial tree in post-pulmonary embolism patients is evolving. Functional testing, in particular cardiopulmonary exercise testing, is emerging as an important modality to quantify and determine cause of functional limitation. It is possible that future investigations of the post-pulmonary embolism recovery period will better inform treatment decisions for acute pulmonary embolism patients.

What should we do about Coronary Calcification on Thoracic CT?

PURPOSE

Coronary artery calcification is a frequent incidental finding on thoracic computed tomography (CT) performed for non-cardiac indications. On electrocardiogram-gated cardiac CT, it is an established marker of coronary artery disease and is associated with increased risk of subsequent cardiac events.

MATERIALS AND METHODS

This review discusses the current evidence and guidelines regarding the reporting of coronary artery calcification on non-electrocardiogram-gated thoracic CT performed for non-cardiac indications.

RESULTS

For patients undergoing routine thoracic CT, coronary artery calcification is associated with an increased risk of myocardial infarction and mortality. Coronary artery calcification can be accurately assessed on non-gated thoracic CT compared to gated CT. Guidelines support the reporting of coronary artery calcification on thoracic CT. However, radiologist opinions vary. The identification of coronary artery calcification on thoracic CT may identify patients with previously unknown coronary artery disease. For asymptomatic patients this may trigger an assessment of modifiable cardiovascular risk factors and guide the appropriate use of preventative medications.

CONCLUSION

Future research will address whether changing management based on calcification on thoracic CT will improve outcomes and automated assessment of calcification using machine learning techniques.

KEY POINTS

· Coronary artery calcification is a frequent incidental finding on thoracic CT.. · The presence and severity of coronary artery calcification is associated with cardiac outcomes and mortality.. · Reporting coronary artery calcification on thoracic CT is supported by national and international guidelines..

CITATION FORMAT

· Williams MC, Llewellyn O, . What Should We Do About Coronary Calcification on Thoracic CT?. Fortschr Röntgenstr 2022; 194: 833 - 840.

Evidence for Left Atrial Volume Being an Indicator of Adverse Events in Patients With Acute Pulmonary Embolism: Retrospective Case-control Pilot Study

PURPOSE

To assess the association between computed tomography pulmonary angiography (CTPA) atrial measurements and both 30-day pulmonary embolism (PE)-related adverse events and mortality, and non-PE-related mortality, and to identify the best predictors of these outcomes by comparing atrial measurements and widely used clinical and imaging variables.

PATIENTS AND METHODS

Retrospective single-center pilot study. Acute PE patients diagnosed on CTPA who also had a transthoracic echocardiogram, electrocardiogram, and troponin T were included. CTPA left atrial (LA) and right atrial (RA) volume and short-axis diameter were measured and compared between outcome groups, along with right ventricular/left ventricular diameter ratio, interventricular septal bowing, tricuspid annular plane systolic excursion, electrocardiogram, and troponin T.

RESULTS

A total of 350 patients. LA volume and diameter were associated with PE-related adverse events (P≤0.01). LA volume was the only atrial measurement associated with PE-related mortality (P=0.03), with no atrial measurements associated with non-PE-related mortality. Troponin was most associated with PE-related adverse events and mortality (both area under the curve [AUC]=0.77). On multivariate analysis, combination models did not greatly improve PE-related adverse events prediction compared with troponin alone. For PE-related mortality, the best models were the combination of troponin, age, and either LA volume (AUC=0.86) or diameter (AUC=0.87).

CONCLUSION

Among patients with acute PE, CTPA LA volume is the only imaging parameter associated with PE-related mortality and is the best imaging predictor of this outcome. Reduced CTPA LA volume and diameter, along with increased RA/LA volume and diameter ratios, are significantly associated with 30-day PE-related adverse events, but not with non-PE-related mortality.

Acute Pulmonary Embolism: Prognostic Role of Computed Tomography Pulmonary Angiography (CTPA)

Computed Tomography Pulmonary Angiography (CTPA) is considered the gold standard diagnostic technique in patients with suspected acute pulmonary embolism in emergency departments. Several studies have been conducted on the predictive value of CTPA on the outcomes of pulmonary embolism (PE). The purpose of this article is to provide an updated review of the literature reporting imaging parameters and quantitative CT scores to predict the severity of PE.