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Nurmohamed NS, van Rosendael AR, Danad I, Ngo-Metzger Q, Taub PR, Ray KK, Figtree G, Bonaca MP, Hsia J, Rodriguez F, Sandhu AT, Nieman K, Earls JP, Hoffmann U, Bax JJ, Min JK, Maron DJ, Bhatt DL. Atherosclerosis evaluation and cardiovascular risk estimation using coronary computed tomography angiography. Eur Heart J 2024; 45:1783-1800. [PMID: 38606889 PMCID: PMC11129796 DOI: 10.1093/eurheartj/ehae190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 02/13/2024] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
Clinical risk scores based on traditional risk factors of atherosclerosis correlate imprecisely to an individual's complex pathophysiological predisposition to atherosclerosis and provide limited accuracy for predicting major adverse cardiovascular events (MACE). Over the past two decades, computed tomography scanners and techniques for coronary computed tomography angiography (CCTA) analysis have substantially improved, enabling more precise atherosclerotic plaque quantification and characterization. The accuracy of CCTA for quantifying stenosis and atherosclerosis has been validated in numerous multicentre studies and has shown consistent incremental prognostic value for MACE over the clinical risk spectrum in different populations. Serial CCTA studies have advanced our understanding of vascular biology and atherosclerotic disease progression. The direct disease visualization of CCTA has the potential to be used synergistically with indirect markers of risk to significantly improve prevention of MACE, pending large-scale randomized evaluation.
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Affiliation(s)
- Nick S Nurmohamed
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit
Amsterdam, Amsterdam, The
Netherlands
- Department of Vascular Medicine, Amsterdam UMC, University of
Amsterdam, Amsterdam, The
Netherlands
- Division of Cardiology, The George Washington University School of
Medicine, Washington, DC, United States
| | | | - Ibrahim Danad
- Department of Cardiology, University Medical Center Utrecht,
Utrecht, The Netherlands
- Department of Cardiology, Radboud University Medical Center,
Nijmegen, The Netherlands
| | - Quyen Ngo-Metzger
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson
School of Medicine, Pasadena, CA, United States
| | - Pam R Taub
- Section of Cardiology, Department of Medicine, University of
California, San Diego, CA, United States
| | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial College
London, London, United
Kingdom
| | - Gemma Figtree
- Faculty of Medicine and Health, University of Sydney,
Australia, St Leonards, Australia
| | - Marc P Bonaca
- Department of Medicine, University of Colorado School of
Medicine, Aurora, CO, United States
| | - Judith Hsia
- Department of Medicine, University of Colorado School of
Medicine, Aurora, CO, United States
| | - Fatima Rodriguez
- Department of Medicine, Stanford University School of
Medicine, Stanford, CA, United States
| | - Alexander T Sandhu
- Department of Medicine, Stanford University School of
Medicine, Stanford, CA, United States
| | - Koen Nieman
- Department of Medicine, Stanford University School of
Medicine, Stanford, CA, United States
| | - James P Earls
- Cleerly, Inc., Denver, CO, United States
- Department of Radiology, The George Washington University School of
Medicine, Washington, DC, United States
| | | | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center,
Leiden, The Netherlands
| | | | - David J Maron
- Department of Medicine, Stanford University School of
Medicine, Stanford, CA, United States
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount
Sinai, 1 Gustave Levy Place, Box 1030, New York, NY
10029, United States
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2
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Clinical application of computed tomography angiography and fractional flow reserve computed tomography in patients with coronary artery disease: A meta-analysis based on pre- and post-test probability. Eur J Radiol 2021; 139:109712. [PMID: 33865062 DOI: 10.1016/j.ejrad.2021.109712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/22/2021] [Accepted: 04/06/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To assess the diagnostic role of coronary computed tomography angiography (CCTA) and fractional flow reserve computed tomography (FFRCT) in confirming or excluding ischemic coronary artery disease (CAD) and to provide a rational use of CCTA and FFRCT in different pre-test probability (PTP) of CAD. METHODS We searched the electronic databases from the earliest relevant literature to July 2020 comparing FFRCT or CCTA with FFR. The bivariate random-effects models and Bayes' theorem were used to investigate the diagnostic performance of CCTA and FFRCT with the sensitivity, specificity, pre- and post-test probability. RESULTS Fifty-three articles with 4817 patients and 7026 vessels finally met our inclusion criteria. At the patient level, the sensitivity and specificity of CCTA were (0.94, 0.89-0.97), and (0.50, 0.43-0.58), respectively. For FFRCT, the sensitivity and specificity were (0.90, 0.87-0.93) and (0.81, 0.73-0.87). CCTA or FFRCT could increase the post-test probability to >85 % in patients with a PTP > 74.9 % or 54.5 %; CCTA or FFRCT could decrease the post-test probability to <15 % in patients with a pre-test probability <61.3 % or 59.3 %. CONCLUSIONS In patients with low to intermediate PTP, CCTA is suggested to exclude CAD, while the time-consuming calculation of FFRCT may be unnecessary. If CCTA detects significant or uncertain stenosis with intermediate to high PTP of CAD, further FFRCT is suggested. The advantages of FFRCT for guiding CAD treatment have sufficiently been demonstrated.
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Bittner DO, Mayrhofer T, Puchner SB, Lu MT, Maurovich-Horvat P, Ghemigian K, Kitslaar PH, Broersen A, Bamberg F, Truong QA, Schlett CL, Hoffmann U, Ferencik M. Coronary Computed Tomography Angiography-Specific Definitions of High-Risk Plaque Features Improve Detection of Acute Coronary Syndrome. Circ Cardiovasc Imaging 2019; 11:e007657. [PMID: 30354493 DOI: 10.1161/circimaging.118.007657] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background High-risk plaque (HRP) features as detected by coronary computed tomography angiography (CTA) predict acute coronary syndrome (ACS). We sought to determine whether coronary CTA-specific definitions of HRP improve discrimination of patients with ACS as compared with definitions from intravascular ultrasound (IVUS). Methods and Results In patients with suspected ACS, randomized to coronary CTA in the ROMICAT II (Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography II) trial, we retrospectively performed semiautomated quantitative analysis of HRP (including remodeling index, plaque burden as derived by plaque area, low computed tomography attenuation plaque volume) and degree of luminal stenosis and analyzed the performance of traditional IVUS thresholds to detect ACS. Furthermore, we derived CTA-specific thresholds in patients with ACS to detect culprit lesions and applied those to all patients to calculate the discriminatory ability to detect ACS in comparison to IVUS thresholds. Of 472 patients, 255 patients (56±7.8 years; 63% men) had coronary plaque. In 32 patients (6.8%) with ACS, culprit plaques (n=35) differed from nonculprit plaques (n=172) with significantly greater values for all HRP features except minimal luminal area (significantly lower; all P<0.01). IVUS definitions showed good performance while minimal luminal area (odds ratio: 6.82; P=0.014) and plaque burden (odds ratio: 5.71; P=0.008) were independently associated with ACS but not remodeling index (odds ratio: 0.78; P=0.673). Optimized CTA-specific thresholds for plaque burden (area under the curve: 0.832 versus 0.676) and degree of stenosis (area under the curve: 0.826 versus 0.721) showed significantly higher diagnostic performance for ACS as compared with IVUS-based thresholds (all P<0.05) with borderline significance for minimal luminal area (area under the curve: 0.817 versus 0.742; P=0.066). Conclusions CTA-specific definitions of HRP features may improve the discrimination of patients with ACS as compared with IVUS-based definitions. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01084239.
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Affiliation(s)
- Daniel O Bittner
- Department of Radiology (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.).,Cardiac MR PET CT Program (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.).,Massachusetts General Hospital and Harvard Medical School, Boston. Department of Cardiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Germany (D.O.B.)
| | - Thomas Mayrhofer
- Department of Radiology (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.).,Cardiac MR PET CT Program (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.).,School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.)
| | - Stefan B Puchner
- Department of Radiology (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.).,Cardiac MR PET CT Program (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.).,Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Austria (S.B.P.)
| | - Michael T Lu
- Department of Radiology (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.).,Cardiac MR PET CT Program (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.)
| | - Pal Maurovich-Horvat
- MTA-SE Lendület Cardiovascular Imaging Research Group, Heart and Vascular Centre, Semmelweis University, Budapest, Hungary (P.M.-H.)
| | - Khristine Ghemigian
- Department of Radiology (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.).,Cardiac MR PET CT Program (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.)
| | - Pieter H Kitslaar
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, the Netherlands (P.H.K., A.B.).,Medis Medical Imaging Systems B.V, Leiden, the Netherlands (P.H.K.)
| | - Alexander Broersen
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, the Netherlands (P.H.K., A.B.)
| | | | - Quynh A Truong
- Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College (Q.A.T.)
| | | | - Udo Hoffmann
- Department of Radiology (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.).,Cardiac MR PET CT Program (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.)
| | - Maros Ferencik
- Department of Radiology (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.).,Cardiac MR PET CT Program (D.O.B., T.M., S.B.P., M.T.L., K.G., U.H., M.F.).,Department of Radiology, University of Tuebingen, Germany (F.B.)
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4
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Poulter R, Wood DA, Starovoytov A, Smith S, Chitsaz M, Mayo J. Quantified dual energy computed tomography perfusion imaging using myocardial iodine concentration: Validation using CT derived myocardial blood flow and invasive fractional flow reserve in a porcine model. J Cardiovasc Comput Tomogr 2019; 13:86-91. [DOI: 10.1016/j.jcct.2019.01.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 01/13/2019] [Accepted: 01/28/2019] [Indexed: 01/07/2023]
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5
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Additional diagnostic value of new CT imaging techniques for the functional assessment of coronary artery disease: a meta-analysis. Eur Radiol 2019; 29:3044-3061. [DOI: 10.1007/s00330-018-5919-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/30/2018] [Accepted: 11/27/2018] [Indexed: 12/14/2022]
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6
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Munnur RK, Cameron JD, McCormick LM, Psaltis PJ, Nerlekar N, Ko BSH, Meredith IT, Seneviratne S, Wong DTL. Diagnostic accuracy of ASLA score (a novel CT angiographic index) and aggregate plaque volume in the assessment of functional significance of coronary stenosis. Int J Cardiol 2018; 270:343-348. [PMID: 29907444 DOI: 10.1016/j.ijcard.2018.06.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 06/05/2018] [Accepted: 06/06/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Visual assessment of diameter-stenosis on Computed Tomography Coronary Angiography (CTCA) lacks specificity to determine functional significance of coronary artery stenosis. Percent-aggregate plaque volume (%APV) and ASLA score, which incorporates Area of Stenosis, Lesion length, and area of myocardium subtended estimated by APPROACH score (Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease) have been described to predict lesion specific ischaemia in focal lesions with intermediate stenosis. METHODS AND RESULTS Included were 81 patients (mean age 64.7 ± 9 years, 62% male; 94 vessels) who underwent 320- detector-row CTCA, invasive coronary angiography and fractional-flow-reserve (FFR). We examined vessels with wide range of diameter stenosis (mid to severe) and with multiple lesions. Invasive FFR of ≤0.8 was considered functionally significant. The first 54 patients (62 vessels) formed the derivation cohort. ASLA score was the best predictor of FFR ≤ 0.8 (AUC 0.83, p < 0.001) compared to %APV (0.72), CT >50% (0.76), APPROACH score (0.79), area-stenosis (0.73), diameter-stenosis (0.74), minimum-luminal-diameter (0.74), minimal-luminal-area (0.72), and lesion-length (0.67). ASLA score and not %APV, provided incremental predictive value when added to CT > 50 [(NRI 0.71, p = 0.005) vs. (NRI 0.01, p = 0.96)]. In the validation cohort of 27 patients (32 vessels), the ASLA score (AUC 0.85) was again a better predictor of FFR ≤ 0.8 compared to %APV (0.71), CT > 50% (0.66) and other CT indices. The AUC of ASLA score was superior to CTCA>50% (p = 0.001). CONCLUSION ASLA score is a novel predictor of functional significance of coronary stenosis and adds incremental predictive value to CT > 50 but %APV did not.
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Affiliation(s)
- Ravi Kiran Munnur
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre) Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168, VIC, Australia.
| | - James D Cameron
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre) Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168, VIC, Australia
| | - Liam M McCormick
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre) Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168, VIC, Australia
| | - Peter J Psaltis
- South Australian Medical Research Institute (SAHMRI), Adelaide, Australia; Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Nitesh Nerlekar
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre) Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168, VIC, Australia
| | - Brian S H Ko
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre) Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168, VIC, Australia
| | - Ian T Meredith
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre) Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168, VIC, Australia
| | - Sujith Seneviratne
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre) Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168, VIC, Australia
| | - Dennis T L Wong
- Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre) Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168, VIC, Australia; South Australian Medical Research Institute (SAHMRI), Adelaide, Australia
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Yim J, Rabkin SW. A patient-specific approach to assessing blood pressure management in patients with hypertension and coronary artery disease. J Clin Hypertens (Greenwich) 2018; 20:233-239. [PMID: 29370480 DOI: 10.1111/jch.13191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/02/2017] [Accepted: 11/07/2017] [Indexed: 11/30/2022]
Abstract
The objective was to improve the management of patients with hypertension (HTN) and coronary artery disease (CAD), utilizing a model which integrates 3 determinants of coronary blood flow (CBF)-CAD severity, diastolic blood pressure (DBP), and left ventricular (LV) mass. We validated non-parametric equations for CBF estimation in a consecutive patient sample (N = 81) with HTN and CAD. There was a highly significant correlation (r = .565; P < .01) between clinical DBP and estimated CBF. Greater LV mass and more severe CAD shifted the relationship towards less CBF at the same DBP. LV mass was more critical when DBP >70 mm Hg. Estimated changes in CBF at different DBP considering the severity of CAD and LV mass can be calculated. In summary, the severity of CAD from coronary CT or coronary angiography combined with LV mass from echocardiography permits clinicians to guide the extent of, or target for, DBP to avoid seriously compromising CBF.
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Affiliation(s)
- Jeffrey Yim
- Department of Medicine (Cardiology), University of British Columbia, Vancouver, BC, Canada
| | - Simon W Rabkin
- Department of Medicine (Cardiology), University of British Columbia, Vancouver, BC, Canada
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Papafaklis MI, Mavrogiannis MC, Siogkas PK, Lakkas LS, Katsouras CS, Fotiadis DI, Michalis LK. Functional assessment of lesion severity without using the pressure wire: coronary imaging and blood flow simulation. Expert Rev Cardiovasc Ther 2017; 15:863-877. [PMID: 28902523 DOI: 10.1080/14779072.2017.1379899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Michail I. Papafaklis
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
- Michailideion Cardiac Center, Medical School, University of Ioannina, Ioannina, Greece
| | | | - Panagiotis K. Siogkas
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science, University of Ioannina, Ioannina, Greece
| | - Lampros S. Lakkas
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Dimitrios I. Fotiadis
- Michailideion Cardiac Center, Medical School, University of Ioannina, Ioannina, Greece
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science, University of Ioannina, Ioannina, Greece
| | - Lampros K. Michalis
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
- Michailideion Cardiac Center, Medical School, University of Ioannina, Ioannina, Greece
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GOVINDARAJU KALIMUTHU, VISWANATHAN GIRISHN, BADRUDDIN IRFANANJUM, WELDEMARIAM SIRAKAREGAWI, GEBREHIWOT WOLDUZINA, KAMANGAR SARFARAZ. THE MECHANICAL FACTORS INFLUENCING THE ASSESSMENT OF INTERMEDIATE STENOSIS SEVERITY EXPLAINED THROUGH FRACTIONAL FLOW RESERVE. J MECH MED BIOL 2017. [DOI: 10.1142/s0219519417300010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Assessment of intermediate coronary lesions with diameter stenosis of 40% to 70% severity is being a challenge for cardiologist to identify potentially ischemic stenosis for revascularization and nonculprit stenosis which can be deferred from stenting. An invasive coronary angiography and intravascular ultrasound provide anatomic information of stenosis severity whereas an invasive fractional flow reserve index (FFR) provides the functional significance of the stenosis severity. The measurement of functional significance of stenosis severity minimizes the procedural complications such as coronary dissection, in stent restenosis etc. rather than anatomical significance measure. The FFR cutoff value of [Formula: see text]0.8 is used to distinguish ischemic and nonischemic stenosis. The FFR is clinically well validated even though it is influenced by the mechanical factors such as hyperemic flow and guide wire insertion. In recent times, noninvasive coronary computed tomography (CCTA) modality has become popular in the diagnosis of coronary artery disease. The CCTA permits the assessment of cross-sectional parameters such as minimum lumen area and lumen diameter, lesion length and plaque morphology. However, the CCTA provides limited information on the functional significance of stenotic lesions as compared to FFR. The purpose of this review is to discuss the mechanical factors influencing the invasive FFR while assessing the functional significance of intermediate stenosis severity. In addition, the hidden mechanical factors influencing the noninvasive CCTA assessment of stenosis severity will be discussed from the critical information obtained from FFR which could be beneficial for the clinician particularly in the assessment of intermediate stenosis severity.
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Affiliation(s)
- KALIMUTHU GOVINDARAJU
- Ethiopian Institute of Technology, School of Mechanical and Industrial Engineering, Mekelle University, Mekelle, Ethiopia
| | | | | | - SIRAK AREGAWI WELDEMARIAM
- Ethiopian Institute of Technology, School of Mechanical and Industrial Engineering, Mekelle University, Mekelle, Ethiopia
| | - WOLDU ZINA GEBREHIWOT
- Ethiopian Institute of Technology, School of Mechanical and Industrial Engineering, Mekelle University, Mekelle, Ethiopia
| | - SARFARAZ KAMANGAR
- Department of Mechanical Engineering, University of Malaya, Malaysia
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Volume and dimensions of angiographically normal coronary arteries assessed by multidetector computed tomography. J Cardiovasc Comput Tomogr 2017; 11:295-301. [DOI: 10.1016/j.jcct.2017.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 03/18/2017] [Accepted: 04/02/2017] [Indexed: 11/24/2022]
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11
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Baumann S, Kryeziu P, Rutsch M, Lossnitzer D. Coronary Computed Tomography Angiography. Interv Cardiol 2017. [DOI: 10.5772/67800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Chu M, Dai N, Yang J, Westra J, Tu S. A systematic review of imaging anatomy in predicting functional significance of coronary stenoses determined by fractional flow reserve. Int J Cardiovasc Imaging 2017; 33:975-990. [PMID: 28265791 DOI: 10.1007/s10554-017-1085-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 01/28/2017] [Indexed: 01/06/2023]
Abstract
Fractional flow reserve (FFR) is the current gold standard to assess the physiological significance of coronary stenoses. With the development of coronary imaging techniques, several anatomic parameters have been investigated in vivo and their associations with FFR have been studied. The aim of this review is to summarize the accuracy of anatomic parameters derived by the present coronary imaging techniques including invasive coronary angiography, coronary computed tomography angiography, intravascular ultrasound and optical coherence tomography, in predicting a significant FFR. The impact of patient characteristics, lesion locations, variability of FFR and imaging resolution on the predictive ability are discussed.
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Affiliation(s)
- Miao Chu
- Biomedical Instrument Institute, School of Biomedical Engineering, Med-X Research Institute, Shanghai Jiao Tong University, No. 1954, Hua Shan Road, Shanghai, 200030, China
| | - Neng Dai
- Cardiovascular Department, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Junqing Yang
- The 3rd Division of Cardiology, Department of Cardiology, Guangdong General Hospital, Guangdong Provincial Cardiovascular Institute, Guangdong Academy of Medical Sciences, No.106, 2nd Zhongshan Road, Yuexiu district, Guangzhou, Guangdong, 510080, China.
| | - Jelmer Westra
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Med-X Research Institute, Shanghai Jiao Tong University, No. 1954, Hua Shan Road, Shanghai, 200030, China.
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Sørgaard MH, Kofoed KF, Linde JJ, George RT, Rochitte CE, Feuchtner G, Lima JA, Abdulla J. Diagnostic accuracy of static CT perfusion for the detection of myocardial ischemia. A systematic review and meta-analysis. J Cardiovasc Comput Tomogr 2016; 10:450-457. [DOI: 10.1016/j.jcct.2016.09.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 07/26/2016] [Accepted: 09/23/2016] [Indexed: 12/28/2022]
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Ding A, Qiu G, Lin W, Hu L, Lu G, Long X, Hong X, Chen Y, Luo X, Tang Q, Deng D. Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in ischemia-causing coronary stenosis: a meta-analysis. Jpn J Radiol 2016; 34:795-808. [DOI: 10.1007/s11604-016-0589-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/28/2016] [Indexed: 12/15/2022]
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Linde JJ, Sørgaard M, Kühl JT, Hove JD, Kelbæk H, Nielsen WB, Kofoed KF. Prediction of clinical outcome by myocardial CT perfusion in patients with low-risk unstable angina pectoris. Int J Cardiovasc Imaging 2016; 33:261-270. [DOI: 10.1007/s10554-016-0994-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 10/03/2016] [Indexed: 01/31/2023]
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Gonçalves PDA, Rodríguez-Granillo GA, Spitzer E, Suwannasom P, Loewe C, Nieman K, Garcia-Garcia HM. Functional Evaluation of Coronary Disease by CT Angiography. JACC Cardiovasc Imaging 2016; 8:1322-35. [PMID: 26563862 DOI: 10.1016/j.jcmg.2015.09.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 08/30/2015] [Accepted: 09/03/2015] [Indexed: 12/24/2022]
Abstract
In recent years, several technical developments in the field of cardiac computed tomography (CT) have made possible the extraction of functional information from an anatomy-based examination. Several different lines have been explored and will be reviewed in the present paper, namely: 1) myocardial perfusion imaging; 2) transluminal attenuation gradients and corrected coronary opacification indexes; 3) fractional flow reserve computed from CT; and 4) extrapolation from atherosclerotic plaque characteristics. In view of these developments, cardiac CT has the potential to become in the near future a truly 2-in-1 noninvasive evaluation for coronary artery disease.
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Affiliation(s)
| | - Gastón A Rodríguez-Granillo
- Department of Cardiovascular Imaging, Diagnostico Maipu, and Consejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET), Buenos Aires, Argentina
| | | | | | - Christian Loewe
- Section of Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Koen Nieman
- Departments of Cardiology and Radiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hector M Garcia-Garcia
- Cardialysis B.V., Rotterdam, the Netherlands; Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands.
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Govindaraju K, Viswanathan GN, Badruddin IA, Kamangar S, Salman Ahmed NJ, Al-Rashed AAAA. The influence of artery wall curvature on the anatomical assessment of stenosis severity derived from fractional flow reserve: a computational fluid dynamics study. Comput Methods Biomech Biomed Engin 2016; 19:1541-9. [PMID: 27052093 DOI: 10.1080/10255842.2016.1170119] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This study aims to investigate the influence of artery wall curvature on the anatomical assessment of stenosis severity and to identify a region of misinterpretation in the assessment of per cent area stenosis (AS) for functionally significant stenosis using fractional flow reserve (FFR) as standard. Five artery models of different per cent AS severity (70, 75, 80, 85 and 90%) were considered. For each per cent AS severity, the angle of curvature of the arterial wall varied from straight to an increasingly curved model (0°, 30°, 60°, 90° and 120°). Computational fluid dynamics was performed under transient physiologic hyperemic flow conditions to investigate the influence of artery wall curvature on the pressure drop and the FFR. The findings in this study may be useful in in vitro anatomical assessment of functionally significant stenosis. The FFR decreased with increasing stenosis severity for a given curvature of the artery wall. Moreover, a significant decrease in FFR was found between straight and curved models discussed for a given severity condition. These findings indicate that the curvature effect was included in the FFR assessment in contrast to minimum lumen area (MLA) or per cent AS assessment. The MLA or per cent AS assessment may lead to underestimation of stenosis severity. From this numerical study, an uncertainty region could be evaluated using the clinical FFR cutoff value of 0.8. This value was observed at 81.98 and 79.10% AS for arteries with curvature angles of 0° and 120° respectively. In conclusion, the curvature of the artery should not be neglected in in vitro anatomical assessment.
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Affiliation(s)
- Kalimuthu Govindaraju
- a Centre for Engineering Programs , HELP College of Arts and Technology , Kuala Lumpur , Malaysia
| | - Girish N Viswanathan
- b Cardiology department , Derriford Hospital , Plymouth , UK.,c Institute of Cellular Medicine , Newcastle University , Newcastle upon Tyne , UK
| | - Irfan Anjum Badruddin
- d Department of Mechanical Engineering , University of Malaya , Kuala Lumpur , Malaysia
| | - Sarfaraz Kamangar
- d Department of Mechanical Engineering , University of Malaya , Kuala Lumpur , Malaysia
| | - N J Salman Ahmed
- e Center for Energy Sciences, Department of Mechanical Engineering , University of Malaya , Kuala Lumpur , Malaysia
| | - Abdullah A A A Al-Rashed
- f Department of Automotive and Marine Engineering Technology , College of Technological Studies, The Public Authority for Applied Education and Training , Kuwait city , Kuwait
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Koo HJ, Yang DH, Kim YH, Kang JW, Kang SJ, Kweon J, Kim HJ, Lim TH. CT-based myocardial ischemia evaluation: quantitative angiography, transluminal attenuation gradient, myocardial perfusion, and CT-derived fractional flow reserve. Int J Cardiovasc Imaging 2015; 32 Suppl 1:1-19. [DOI: 10.1007/s10554-015-0825-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 12/08/2015] [Indexed: 12/18/2022]
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Gonzalez JA, Lipinski MJ, Flors L, Shaw PW, Kramer CM, Salerno M. Meta-Analysis of Diagnostic Performance of Coronary Computed Tomography Angiography, Computed Tomography Perfusion, and Computed Tomography-Fractional Flow Reserve in Functional Myocardial Ischemia Assessment Versus Invasive Fractional Flow Reserve. Am J Cardiol 2015; 116:1469-78. [PMID: 26347004 DOI: 10.1016/j.amjcard.2015.07.078] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/29/2015] [Accepted: 07/29/2015] [Indexed: 12/13/2022]
Abstract
We sought to compare the diagnostic performance of coronary computed tomography angiography (CCTA), computed tomography perfusion (CTP), and computed tomography (CT)-fractional flow reserve (FFR) for assessing the functional significance of coronary stenosis as defined by invasive FFR in patients with known or suspected coronary artery disease (CAD). CCTA has proved clinically useful for excluding obstructive CAD because of its high sensitivity and negative predictive value (NPV); however, the ability of CTA to identify functionally significant CAD has remained challenging. We searched PubMed/Medline for studies evaluating CCTA, CTP, or CT-FFR for the noninvasive detection of obstructive CAD compared with catheter-derived FFR as the reference standard. Pooled sensitivity, specificity, PPV, NPV, likelihood ratios, and odds ratio of all diagnostic tests were assessed. Eighteen studies involving a total of 1,535 patients were included. CTA demonstrated a pooled sensitivity of 0.92, specificity 0.43, PPV of 0.56, and NPV of 0.87 on a per-patient level. CT-FFR and CTP increased the specificity to 0.72 and 0.77, respectively (p = 0.004 and p = 0.0009) resulting in higher point estimates for PPV 0.70 and 0.83, respectively. There was no improvement in the sensitivity. The CTP protocol involved more radiation (3.5 mSv CCTA vs 9.6 mSv CTP) and a higher volume of iodinated contrast (145 ml). In conclusion, CTP and CT-FFR improve the specificity of CCTA for detecting functionally significant stenosis as defined by invasive FFR on a per-patient level; both techniques could advance the ability to noninvasively detect the functional significance of coronary lesions.
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Park HB, Heo R, Ó Hartaigh B, Cho I, Gransar H, Nakazato R, Leipsic J, Mancini GBJ, Koo BK, Otake H, Budoff MJ, Berman DS, Erglis A, Chang HJ, Min JK. Atherosclerotic plaque characteristics by CT angiography identify coronary lesions that cause ischemia: a direct comparison to fractional flow reserve. JACC Cardiovasc Imaging 2015; 8:1-10. [PMID: 25592691 DOI: 10.1016/j.jcmg.2014.11.002] [Citation(s) in RCA: 221] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 11/05/2014] [Accepted: 11/06/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVES This study evaluated the association between atherosclerotic plaque characteristics (APCs) by coronary computed tomographic angiography (CTA), and lesion ischemia by fractional flow reserve (FFR). BACKGROUND FFR is the gold standard for determining lesion ischemia. Although APCs by CTA-including aggregate plaque volume % (%APV), positive remodeling (PR), low attenuation plaque (LAP), and spotty calcification (SC)-are associated with future coronary syndromes, their relationship to lesion ischemia is unclear. METHODS 252 patients (17 centers, 5 countries; mean age 63 years; 71% males) underwent coronary CTA, with FFR performed for 407 coronary lesions. Coronary CTA was interpreted for <50% and ≥50% stenosis, with the latter considered obstructive. APCs by coronary CTA were defined as: 1) PR, lesion diameter/reference diameter >1.10; 2) LAP, any voxel <30 Hounsfield units; and 3) SC, nodular calcified plaque <3 mm. Odds ratios (OR) and net reclassification improvement of APCs for lesion ischemia, defined by FFR ≤0.8, were analyzed. RESULTS By FFR, ischemia was present in 151 lesions (37%). %APV was associated with a 50% increased risk of ischemia per 5% additional APV. PR, LAP, and SC were associated with ischemia, with a 3 to 5 times higher prevalence than in nonischemic lesions. In multivariable analyses, a stepwise increased risk of ischemia was observed for 1 (OR: 4.0, p < 0.001) and ≥2 (OR: 12.1, p < 0.001) APCs. These findings were APC dependent, with PR (OR: 5.3, p < 0.001) and LAP (OR: 2.1, p = 0.038) associated with ischemia, but not SC. When examined by stenosis severity, PR remained a predictor of ischemia for all lesions, whereas %APV and LAP were associated with ischemia for only ≥50%, but not for <50%, stenosis. CONCLUSIONS %APV and APCs by coronary CTA improve identification of coronary lesions that cause ischemia. PR is associated with all ischemia-causing lesions, whereas %APV and LAP are only associated with ischemia-causing lesions ≥50%. (Determination of Fractional Flow Reserve by Anatomic Computed Tomographic Angiography; NCT01233518).
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Affiliation(s)
- Hyung-Bok Park
- Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York; Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, South Korea; Cardiovascular Center, Myongji Hospital, Goyang, Korea
| | - Ran Heo
- Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York; Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Bríain Ó Hartaigh
- Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York
| | - Iksung Cho
- Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York; Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Heidi Gransar
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ryo Nakazato
- Cardiovascular Center, St. Luke's International Hospital, Tokyo, Japan
| | - Jonathon Leipsic
- Department of Radiology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - G B John Mancini
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Bon-Kwon Koo
- Department of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hiromasa Otake
- Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Matthew J Budoff
- Department of Medicine, Harbor UCLA Medical Center, Los Angeles, California
| | - Daniel S Berman
- Departments of Imaging and Medicine, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrejs Erglis
- Department of Medicine, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - James K Min
- Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York.
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Diagnostic performance of quantitative coronary computed tomography angiography and quantitative coronary angiography to predict hemodynamic significance of intermediate-grade stenoses. Int J Cardiovasc Imaging 2015; 31:1651-61. [DOI: 10.1007/s10554-015-0748-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 08/17/2015] [Indexed: 01/14/2023]
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Hell MM, Achenbach S, Shah PK, Berman DS, Dey D. Noncalcified Plaque in Cardiac CT: Quantification and Clinical Implications. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015. [DOI: 10.1007/s12410-015-9343-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Diaz-Zamudio M, Dey D, Schuhbaeck A, Nakazato R, Gransar H, Slomka PJ, Narula J, Berman DS, Achenbach S, Min JK, Doh JH, Koo BK. Automated Quantitative Plaque Burden from Coronary CT Angiography Noninvasively Predicts Hemodynamic Significance by using Fractional Flow Reserve in Intermediate Coronary Lesions. Radiology 2015; 276:408-15. [PMID: 25897475 DOI: 10.1148/radiol.2015141648] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate the utility of multiple automated plaque measurements from coronary computed tomographic (CT) angiography in determining hemodynamic significance by using invasive fractional flow reserve (FFR) in patients with intermediate coronary stenosis. MATERIALS AND METHODS The study was approved by the institutional review board. All patients provided written informed consent. Fifty-six intermediate lesions (with 30%-69% diameter stenosis) in 56 consecutive patients (mean age, 62 years; range, 46-88 years), who subsequently underwent invasive coronary angiography with assessment of FFR (values ≤0.80 were considered hemodynamically significant) were analyzed at coronary CT angiography. Coronary CT angiography images were quantitatively analyzed with automated software to obtain the following measurements: volume and burden (plaque volume × 100 per vessel volume) of total, calcified, and noncalcified plaque; low-attenuation (<30 HU) noncalcified plaque; diameter stenosis; remodeling index; contrast attenuation difference (maximum percent difference in attenuation per unit area with respect to the proximal reference cross section); and lesion length. Logistic regression adjusted for potential confounding factors, receiver operating characteristics, and integrated discrimination improvement were used for statistical analysis. RESULTS FFR was 0.80 or less in 21 (38%) of the 56 lesions. Compared with nonischemic lesions, ischemic lesions had greater diameter stenosis (65% vs 52%, P = .02) and total (49% vs 37%, P = .0003), noncalcified (44% vs 33%, P = .0004), and low-attenuation noncalcified (9% vs 4%, P < .0001) plaque burden. Calcified plaque and remodeling index were not significantly different. In multivariable analysis, only total, noncalcified, and low-attenuation noncalcified plaque burden were significant predictors of ischemia (P < .015). For predicting ischemia, the area under the receiver operating characteristics curve was 0.83 for total plaque burden versus 0.68 for stenosis (P = .04). CONCLUSION Compared with stenosis grading, automatic quantification of total, noncalcified, and low-attenuation noncalcified plaque burden substantially improves determination of lesion-specific hemodynamic significance by FFR in patients with intermediate coronary lesions.
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Affiliation(s)
- Mariana Diaz-Zamudio
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Damini Dey
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Annika Schuhbaeck
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Ryo Nakazato
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Heidi Gransar
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Piotr J Slomka
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Jagat Narula
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Daniel S Berman
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Stephan Achenbach
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - James K Min
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Joon-Hyung Doh
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
| | - Bon-Kwon Koo
- From the Department of Imaging and Medicine, Division of Nuclear Medicine (M.D.Z., R.N., H.G., P.J.S., D.S.B.), and Biomedical Imaging Research Institute (D.D.), Cedars-Sinai Medical Center, 8700 Beverly Blvd, S. Mark Taper Building A238, Los Angeles, CA 90048; Department of Internal Medicine 2, University of Erlangen, Erlangen, Germany (A.S., S.A.); Cardiovascular Institute, Mount Sinai Medical Center, New York, NY (J.N.); Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (J.K.M.); Department of Medicine, Inje University Ilsan-Paik Hospital, Goyang, South Korea (J.H.D.); and Department of Medicine, Seoul National University Hospital, Seoul, South Korea (B.K.K.)
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Ko BS, Wong DTL, Cameron JD, Leong DP, Soh S, Nerlekar N, Meredith IT, Seneviratne SK. The ASLA Score: A CT Angiographic Index to Predict Functionally Significant Coronary Stenoses in Lesions with Intermediate Severity-Diagnostic Accuracy. Radiology 2015; 276:91-101. [PMID: 25710278 DOI: 10.1148/radiol.15141231] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To identify computed tomographic (CT) coronary indexes independently associated with a fractional flow reserve (FFR) of 0.8 or less, to derive a score that combines CT indexes most predictive of an FFR of 0.8 or less, and to evaluate the diagnostic accuracy of the score in predicting an FFR of 0.8 or less. MATERIALS AND METHODS This retrospective study had institutional review board approval and waiver of the need to obtain informed consent. Consecutive patients who underwent CT coronary angiography and FFR assessment with one or more discrete lesion(s) of intermediate (30%-70%) severity at CT were included. Quantitative CT measurements were performed by using dedicated software. The CT indexes evaluated included the following: plaque burden, minimal luminal area and diameter, stenosis diameter, area of stenosis, lesion length, remodeling index, plaque morphology, calcification severity, and the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) score, which approximates the size of the myocardium subtended by a lesion. By using covariates independently associated with an FFR of 0.8 or less, a score was determined on the basis of modified Akaike information criteria, and the C statistics of individual and combined indexes were compared. RESULTS Eighty-five patients (mean age, 64.2 years; range, 48-88 years; 65.9% men; 124 lesions; 38 lesions with an FFR ≤ 0.8) were included. Area of stenosis, lesion length, and APPROACH score were the strongest predictors of an FFR of 0.8 or less and were used to derive the ASLA score. The optimism-adjusted Harrell C statistic for the combined score was 0.82, which was superior to that for area of stenosis (0.74), lesion length (0.75), and the APPROACH score (0.71) (P < .001 for trend). The corresponding incremental discrimination improvement indexes were 0.17, 0.11, and 0.19, respectively (P < .001 for all), suggesting that the score improves reclassification compared with any one angiographic index. The average time required for score derivation was 102.6 seconds. CONCLUSION The ASLA score, which accounts for CT-derived area of stenosis, lesion length, and APPROACH score, may conveniently improve the prediction, beyond individual indexes, of functionally significant intermediate coronary lesions.
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Affiliation(s)
- Brian S Ko
- From the Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168 VIC, Australia (B.S.K., D.T.L.W., J.D.C., S.S., N.N., I.T.M., S.K.S.); Discipline of Medicine, University of Adelaide, Adelaide, Australia (D.T.L.W., D.P.L.); and Discipline of Medicine, Flinders University, Adelaide, Australia (D.P.L.)
| | - Dennis T L Wong
- From the Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168 VIC, Australia (B.S.K., D.T.L.W., J.D.C., S.S., N.N., I.T.M., S.K.S.); Discipline of Medicine, University of Adelaide, Adelaide, Australia (D.T.L.W., D.P.L.); and Discipline of Medicine, Flinders University, Adelaide, Australia (D.P.L.)
| | - James D Cameron
- From the Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168 VIC, Australia (B.S.K., D.T.L.W., J.D.C., S.S., N.N., I.T.M., S.K.S.); Discipline of Medicine, University of Adelaide, Adelaide, Australia (D.T.L.W., D.P.L.); and Discipline of Medicine, Flinders University, Adelaide, Australia (D.P.L.)
| | - Darryl P Leong
- From the Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168 VIC, Australia (B.S.K., D.T.L.W., J.D.C., S.S., N.N., I.T.M., S.K.S.); Discipline of Medicine, University of Adelaide, Adelaide, Australia (D.T.L.W., D.P.L.); and Discipline of Medicine, Flinders University, Adelaide, Australia (D.P.L.)
| | - Siang Soh
- From the Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168 VIC, Australia (B.S.K., D.T.L.W., J.D.C., S.S., N.N., I.T.M., S.K.S.); Discipline of Medicine, University of Adelaide, Adelaide, Australia (D.T.L.W., D.P.L.); and Discipline of Medicine, Flinders University, Adelaide, Australia (D.P.L.)
| | - Nitesh Nerlekar
- From the Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168 VIC, Australia (B.S.K., D.T.L.W., J.D.C., S.S., N.N., I.T.M., S.K.S.); Discipline of Medicine, University of Adelaide, Adelaide, Australia (D.T.L.W., D.P.L.); and Discipline of Medicine, Flinders University, Adelaide, Australia (D.P.L.)
| | - Ian T Meredith
- From the Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168 VIC, Australia (B.S.K., D.T.L.W., J.D.C., S.S., N.N., I.T.M., S.K.S.); Discipline of Medicine, University of Adelaide, Adelaide, Australia (D.T.L.W., D.P.L.); and Discipline of Medicine, Flinders University, Adelaide, Australia (D.P.L.)
| | - Sujith K Seneviratne
- From the Monash Cardiovascular Research Centre, Department of Medicine (Monash Medical Centre), Monash University and Monash Heart, Monash Health, 246 Clayton Road, Clayton, 3168 VIC, Australia (B.S.K., D.T.L.W., J.D.C., S.S., N.N., I.T.M., S.K.S.); Discipline of Medicine, University of Adelaide, Adelaide, Australia (D.T.L.W., D.P.L.); and Discipline of Medicine, Flinders University, Adelaide, Australia (D.P.L.)
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Yang HM, Tahk SJ, Lim HS, Yoon MH, Choi SY, Choi BJ, Jin XJ, Hwang GS, Park JS, Shin JH. Relationship between intravascular ultrasound parameters and fractional flow reserve in intermediate coronary artery stenosis of left anterior descending artery: intravascular ultrasound volumetric analysis. Catheter Cardiovasc Interv 2014; 83:386-94. [PMID: 23804359 DOI: 10.1002/ccd.25088] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 06/15/2013] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The objective of this study was to assess the relationship between intravascular ultrasound (IVUS) parameters, including volumetric analysis, and fractional flow reserve (FFR). BACKGROUND Although it is known that coronary atherosclerosis burden measured by IVUS volumetric analysis is related with clinical outcomes, its relationship with functional significance remains unknown. METHODS Both IVUS and FFR were performed in 206 cases of intermediate stenosis of the left anterior descending artery (LAD). Myocardial ischemia was assessed by FFR and maximal hyperemia was induced by continuous intracoronary adenosine infusion. FFR < 0.80 was considered as significant inducible myocardial ischemia. We performed standard IVUS parameter measurements and volumetric analyses. IVUS parameter comparison was performed in the presence (n = 90) or absence (n =116) of significant myocardial ischemia. RESULTS Lesions with minimal lumen area (MLA) ≥ 4.0 mm2 had FFR ≥ 0.80 in 91.4% of cases, while 50.9% of lesions with MLA < 4.0 mm2 had FFR < 0.80. The independent predictors of FFR < 0.80 were IVUS lesion length (odds ratio [OR]: 1.1, 95% confidence interval [CI] = 1.06–1.18, P < 0.001) and MLA significance according to the lesion location (OR: 7.01, 95% CI = 3.09–15.92, P = 0.001). FFR correlated with plaque volume (r = −0.345, P < 0.001) and percent atheroma volume (PAV) (r = −0.398, P < 0.001). Lesions with significant ischemia (FFR < 0.80) as compared to those with FFR > 0.80 were associated with larger plaque volume (181.8 ± 82.3 vs. 125.9 ± 77.9 mm3, P < 0.001) and PAV (58.9 ± 5.6 vs. 53.8 ± 7.9%, P < 0.001). CONCLUSIONS IVUS parameters representing severity and extent of atheromatous plaque correlated with functional significance in LAD lesions with intermediate stenosis.
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Clinical feasibility of myocardial computed tomographic perfusion imaging in patients with recent acute-onset chest pain. Int J Cardiol 2014; 174:195-7. [DOI: 10.1016/j.ijcard.2014.03.209] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 03/31/2014] [Indexed: 11/24/2022]
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Yongzhen F, Jeon KH, Doh JH, Koo BK. Noninvasive and Invasive Assessments of the Functional Significance of Intermediate Coronary Artery Stenosis: Is This a Matter of Right or Wrong? Pulse (Basel) 2014; 2:52-6. [PMID: 26587444 DOI: 10.1159/000369837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Coronary computed tomographic angiography (cCTA) has emerged in recent years as a noninvasive modality to evaluate coronary artery disease. Many studies have revealed the excellent diagnostic accuracy of cCTA when compared with invasive coronary angiography (ICA) or intravascular ultrasound (IVUS). It is generally accepted that the functional significance of coronary artery stenosis is important to make treatment decisions; however, cCTA, ICA, and IVUS are limited in the ability to determine the physiologic significance of coronary stenosis. The FIGURE-OUT study compared the noninvasive and invasive assessment of the functional significance of intermediate coronary artery stenosis.
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Affiliation(s)
- Fan Yongzhen
- Department of Medicine, Seoul National University Hospital, Seoul, Korea ; Xiangtan Central Hospital, Changde, China
| | - Ki-Hyun Jeon
- Department of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Bon-Kwon Koo
- Department of Medicine, Seoul National University Hospital, Seoul, Korea
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28
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Govindaraju K, Kamangar S, Badruddin IA, Viswanathan GN, Badarudin A, Salman Ahmed N. Effect of porous media of the stenosed artery wall to the coronary physiological diagnostic parameter: A computational fluid dynamic analysis. Atherosclerosis 2014; 233:630-635. [DOI: 10.1016/j.atherosclerosis.2014.01.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 01/05/2014] [Accepted: 01/20/2014] [Indexed: 11/28/2022]
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Doh JH, Koo BK, Nam CW, Kim JH, Min JK, Nakazato R, Silalahi T, Prawira H, Choi H, Lee SY, Namgung J, Kwon SU, Kwak JJ, Lee WR. Diagnostic value of coronary CT angiography in comparison with invasive coronary angiography and intravascular ultrasound in patients with intermediate coronary artery stenosis: results from the prospective multicentre FIGURE-OUT (Functional Imaging criteria for GUiding REview of invasive coronary angiOgraphy, intravascular Ultrasound, and coronary computed Tomographic angiography) study. Eur Heart J Cardiovasc Imaging 2014; 15:870-7. [PMID: 24513881 DOI: 10.1093/ehjci/jeu009] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS The anatomical criteria for the diagnosis of ischaemia referenced by fractional flow reserve (FFR) from non-invasive coronary computed tomographic angiography (CCTA), invasive coronary angiography (ICA), and intravascular ultrasound (IVUS) have not been evaluated contemporarily in a large-scale study. The aim of this study was to assess the diagnostic value of CCTA compared with ICA and IVUS in patients with intermediate coronary stenosis. METHODS AND RESULTS CCTA, ICA, IVUS, and FFR were performed in 181 coronary lesions with intermediate severity. Minimal lumen diameter (MLD) and per cent diameter stenosis (%DS) were determined by CCTA and ICA, whereas minimal lumen area (MLA) was determined by CCTA and IVUS. Inducible ischaemia was defined by FFR ≤ 0.80. Diagnostic performances from non-invasive and invasive methods were compared. FFR ≤ 0.80 was observed in 49 (27.1%) lesions. CCTA MLD was smaller than ICA MLD (1.3 ± 0.5 vs. 1.5 ± 0.4 mm, P < 0.001), CCTA %DS was higher than ICA %DS (54.0 ± 14.0 vs. 50.3 ± 12.8%, P < 0.001), and CCTA MLA was smaller than IVUS MLA (2.2 ± 1.2 vs. 3.2 ± 1.2 mm(2), P < 0.001). This trend was consistent irrespective of lesion location, lesion severity, and plaque characteristics. For the determination of ischaemia, diagnostic performance of CCTA %DS was lower than ICA %DS [area under the curve (AUC) 0.657 vs. 0.765, P = 0.04], and that of CCTA MLA was lower than IVUS MLA (AUC 0.712 vs. 0.801, P = 0.03). CONCLUSION Anatomical criteria for the diagnosis of ischaemia-producing coronary stenosis differ by non-invasive and invasive methods. Compared with invasive methods, CCTA presents overestimation in assessing lesion severity and lower diagnostic performance in assessing ischaemia.
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Affiliation(s)
- Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Bon-Kwon Koo
- Department of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chang-Wook Nam
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Ji-Hyun Kim
- Department of Medicine, Dongguk University Ilsan Hospital, Dongguk University Graduate School, Goyang, Korea
| | - James K Min
- Department of Imaging and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ryo Nakazato
- Department of Imaging and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Hyunmin Choi
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sung Yun Lee
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - June Namgung
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sung Uk Kwon
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jae-Jin Kwak
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Won Ro Lee
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
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Dey D, Schuhbaeck A, Min JK, Berman DS, Achenbach S. Non-invasive measurement of coronary plaque from coronary CT angiography and its clinical implications. Expert Rev Cardiovasc Ther 2014; 11:1067-77. [DOI: 10.1586/14779072.2013.823707] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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31
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Opolski MP, Kepka C, Achenbach S, Pregowski J, Kruk M, Staruch AD, Kadziela J, Ruzyllo W, Witkowski A. Advanced computed tomographic anatomical and morphometric plaque analysis for prediction of fractional flow reserve in intermediate coronary lesions. Eur J Radiol 2014; 83:135-41. [DOI: 10.1016/j.ejrad.2013.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 08/05/2013] [Accepted: 10/06/2013] [Indexed: 10/26/2022]
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Rossi A, Papadopoulou SL, Pugliese F, Russo B, Dharampal AS, Dedic A, Kitslaar PH, Broersen A, Meijboom WB, van Geuns RJ, Wragg A, Ligthart J, Schultz C, Petersen SE, Nieman K, Krestin GP, de Feyter PJ. Quantitative Computed Tomographic Coronary Angiography. Circ Cardiovasc Imaging 2014; 7:43-51. [DOI: 10.1161/circimaging.112.000277] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Coronary lesions with a diameter narrowing ≥50% on visual computed tomographic coronary angiography (CTCA) are generally considered for referral to invasive coronary angiography. However, similar to invasive coronary angiography, visual CTCA is often inaccurate in detecting functionally significant coronary lesions. We sought to compare the diagnostic performance of quantitative CTCA with visual CTCA for the detection of functionally significant coronary lesions using fractional flow reserve (FFR) as the reference standard.
Methods and Results—
CTCA and FFR measurements were obtained in 99 symptomatic patients. In total, 144 coronary lesions detected on CTCA were visually graded for stenosis severity. Quantitative CTCA measurements included lesion length, minimal area diameter, % area stenosis, minimal lumen diameter, % diameter stenosis, and plaque burden [(vessel area−lumen area)/vessel area×100]. Optimal cutoff values of CTCA-derived parameters were determined, and their diagnostic accuracy for the detection of flow-limiting coronary lesions (FFR ≤0.80) was compared with visual CTCA. FFR was ≤0.80 in 54 of 144 (38%) coronary lesions. Optimal cutoff values to predict flow-limiting coronary lesion were 10 mm for lesion length, 1.8 mm
2
for minimal area diameter, 73% for % area stenosis, 1.5 mm for minimal lumen diameter, 48% for % diameter stenosis, and 76% for plaque burden. No significant difference in sensitivity was found between visual CTCA and quantitative CTCA parameters (
P
>0.05). The specificity of visual CTCA (42%; 95% confidence interval [CI], 31%–54%) was lower than that of minimal area diameter (68%; 95% CI, 57%–77%;
P
=0.001), % area stenosis (76%; 95% CI, 65%–84%;
P
<0.001), minimal lumen diameter (67%; 95% CI, 55%–76%;
P
=0.001), % diameter stenosis (72%; 95% CI, 62%–80%;
P
<0.001), and plaque burden (63%; 95% CI, 52%–73%;
P
=0.004). The specificity of lesion length was comparable with that of visual CTCA.
Conclusions—
Quantitative CTCA improves the prediction of functionally significant coronary lesions compared with visual CTCA assessment but remains insufficient. Functional assessment is still required in lesions of moderate stenosis to accurately detect impaired FFR.
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Affiliation(s)
- Alexia Rossi
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Stella-Lida Papadopoulou
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Francesca Pugliese
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Brunella Russo
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Anoeshka S. Dharampal
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Admir Dedic
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Pieter H. Kitslaar
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Alexander Broersen
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - W. Bob Meijboom
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Robert-Jan van Geuns
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Andrew Wragg
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Jurgen Ligthart
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Carl Schultz
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Steffen E. Petersen
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Koen Nieman
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Gabriel P. Krestin
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
| | - Pim J. de Feyter
- From the Department of Radiology (A.R., S.-L.P., B.R., A.S.D., A.D., R.-J.v.G., K.N., P.J.d.F.) and Department of Cardiology (A.R., S.-L.P., A.S.D., A.D., W.B.M., R.-J.v.G., J.L., C.S., K.N., G.P.K., P.J.d.F.), Erasmus University Medical Center, Rotterdam, The Netherlands; Centre for Advanced Cardiovascular Imaging, NIHR Cardiovascular Biomedical Research Unit at Barts, Barts and The London School of Medicine & Barts Health NHS Trust, London, United Kingdom (F.P., A.W., S.E.P.); and Division of
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Sun Z. Coronary CT angiography: Beyond morphological stenosis analysis. World J Cardiol 2013; 5:444-452. [PMID: 24392188 PMCID: PMC3879698 DOI: 10.4330/wjc.v5.i12.444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 10/04/2013] [Accepted: 11/19/2013] [Indexed: 02/06/2023] Open
Abstract
Rapid technological developments in computed tomography (CT) imaging technique have made coronary CT angiography an attractive imaging tool in the detection of coronary artery disease. Despite visualization of excellent anatomical details of the coronary lumen changes, coronary CT angiography does not provide hemodynamic changes caused by presence of plaques. Computational fluid dynamics (CFD) is a widely used method in the mechanical engineering field to solve complex problems through analysing fluid flow, heat transfer and associated phenomena by using computer simulations. In recent years, CFD is increasingly used in biomedical research due to high performance hardware and software. CFD techniques have been used to study cardiovascular hemodynamics through simulation tools to assist in predicting the behaviour of circulatory blood flow inside the human body. Blood flow plays a key role in the localization and progression of coronary artery disease. CFD simulation based on 3D luminal reconstructions can be used to analyse the local flow fields and flow profiling due to changes of vascular geometry, thus, identifying risk factors for development of coronary artery disease. The purpose of this article is to provide an overview of the coronary CT-derived CFD applications in coronary artery disease.
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Foin N, Sen S, Petraco R, Nijjer S, Torii R, Kousera C, Broyd C, Mehta V, Xu Y, Mayet J, Hughes A, Di Mario C, Krams R, Francis D, Davies J. Method for percutaneously introducing, and removing, anatomical stenosis of predetermined severity in vivo: the "stenotic stent". J Cardiovasc Transl Res 2013; 6:640-8. [PMID: 23733543 DOI: 10.1007/s12265-013-9476-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 05/15/2013] [Indexed: 11/30/2022]
Abstract
Current in vivo models of arterial lesions often lead to unpredictable results in terms of lesion anatomy and hemodynamical significance. This study aimed to evaluate the impact of coronary stenosis using a novel in vivo adjustable stenosis model capable of mimicking advanced human coronary lesions. We developed a series of balloon expandable covered coronary stents with a central restriction, mimicking different intermediate to severe stenosis, and implanted them percutaneously in coronary arteries of eight healthy hybrid Landrace pigs. Optical coherence tomography (OCT) pullbacks and fractional flow reserve (FFR) were acquired along the artery after implantation of the stenotic stents for precise evaluation of anatomy and functional impact. Diameter and area stenosis after deployment of the stenosis implant were, on average, respectively, 54.1 ± 5.9 and 78.4 ± 5.8 % and average FFR value was 0.83 (SD 0.13). There was a low correlation between FFR and MLA evaluated by OCT (r = 0.02, p = 0.94), improved with percentage area stenosis (r = -0.55, p = 0.12), or OCT volumetric evaluation of the stenosis taking into account not only the MLA but also the length of the lesion (r = -0.78, p = 0.01). This study presents a method and proof of concept for percutaneously introducing, and removing, anatomical stenosis of predetermined severity in vivo. Such in vivo model may be used to create and evaluate the impact of focal stenoses on physiological parameters such as FFR.
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Affiliation(s)
- Nicolas Foin
- International Centre for Circulatory Health, NHLI, Imperial College London, London, UK.
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Nakazato R, Shalev A, Doh JH, Koo BK, Gransar H, Gomez MJ, Leipsic J, Park HB, Berman DS, Min JK. Aggregate plaque volume by coronary computed tomography angiography is superior and incremental to luminal narrowing for diagnosis of ischemic lesions of intermediate stenosis severity. J Am Coll Cardiol 2013; 62:460-7. [PMID: 23727206 DOI: 10.1016/j.jacc.2013.04.062] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 04/02/2013] [Accepted: 04/07/2013] [Indexed: 01/06/2023]
Abstract
OBJECTIVES This study examined the performance of percent aggregate plaque volume (%APV), which represents cumulative plaque volume as a function of total vessel volume, by coronary computed tomography angiography (CTA) for identification of ischemic lesions of intermediate stenosis severity. BACKGROUND Coronary lesions of intermediate stenosis demonstrate significant rates of ischemia. Coronary CTA enables quantification of luminal narrowing and %APV. METHODS We identified 58 patients with intermediate lesions (30% to 69% diameter stenosis) who underwent invasive angiography and fractional flow reserve. Coronary CTA measures included diameter stenosis, area stenosis, minimal lumen diameter (MLD), minimal lumen area (MLA) and %APV. %APV was defined as the sum of plaque volume divided by the sum of vessel volume from the ostium to the distal portion of the lesion. Fractional flow reserve ≤ 0.80 was considered diagnostic of lesion-specific ischemia. Area under the receiver operating characteristic curve and net reclassification improvement (NRI) were also evaluated. RESULTS Twenty-two of 58 lesions (38%) caused ischemia. Compared with nonischemic lesions, ischemic lesions had smaller MLD (1.3 vs. 1.7 mm, p = 0.01), smaller MLA (2.5 vs. 3.8 mm(2), p = 0.01), and greater %APV (48.9% vs. 39.3%, p < 0.0001). Area under the receiver operating characteristic curve was highest for %APV (0.85) compared with diameter stenosis (0.68), area stenosis (0.66), MLD (0.75), or MLA (0.78). Addition of %APV to other measures showed significant reclassification over diameter stenosis (NRI 0.77, p < 0.001), area stenosis (NRI 0.63, p = 0.002), MLD (NRI 0.62, p = 0.001), and MLA (NRI 0.43, p = 0.01). CONCLUSIONS Compared with diameter stenosis, area stenosis, MLD, and MLA, %APV by coronary CTA improves identification, discrimination, and reclassification of ischemic lesions of intermediate stenosis severity.
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Affiliation(s)
- Ryo Nakazato
- Division of Nuclear Medicine, Department of Imaging, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Characteristics of High-Risk Plaques as Identified on Coronary Computed Tomography Angiography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9149-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ferencik M, Schlett CL, Ghoshhajra BB, Kriegel MF, Joshi SB, Maurovich-Horvat P, Rogers IS, Banerji D, Bamberg F, Truong QA, Brady TJ, Nagurney JT, Hoffmann U. A computed tomography-based coronary lesion score to predict acute coronary syndrome among patients with acute chest pain and significant coronary stenosis on coronary computed tomographic angiogram. Am J Cardiol 2012; 110:183-9. [PMID: 22481015 DOI: 10.1016/j.amjcard.2012.02.066] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 02/28/2012] [Accepted: 02/28/2012] [Indexed: 11/16/2022]
Abstract
We tested the hypothesis that morphologic lesion assessment helps detect acute coronary syndrome (ACS) during index hospitalization in patients with acute chest pain and significant stenosis on coronary computed tomographic angiogram (CTA). Patients who presented to an emergency department with chest pain but no objective signs of myocardial ischemia (nondiagnostic electrocardiogram and negative initial biomarkers) underwent CT angiography. CTA was analyzed for degree and length of stenosis, plaque area and volume, remodeling index, CT attenuation of plaque, and spotty calcium in all patients with significant stenosis (>50% in diameter) on CTA. ACS during index hospitalization was determined by a panel of 2 physicians blinded to results of CT angiography. For lesion characteristics associated with ACS, we determined cutpoints optimized for diagnostic accuracy and created lesion scores. For each score, we determined the odds ratio (OR) and discriminatory capacity for the prediction of ACS. Of the overall population of 368 patients, 34 had significant stenosis and 21 of those had ACS. Scores A (remodeling index plus spotty calcium: OR 3.5, 95% confidence interval [CI] 1.2 to 10.1, area under curve [AUC] 0.734), B (remodeling index plus spotty calcium plus stenosis length: OR 4.6, 95% CI 1.6 to 13.7, AUC 0.824), and C (remodeling index plus spotty calcium plus stenosis length plus plaque volume <90 HU: OR 3.4, 95% CI 1.5 to 7.9, AUC 0.833) were significantly associated with ACS. In conclusion, in patients presenting with acute chest pain and stenosis on coronary CTA, a CT-based score incorporating morphologic characteristics of coronary lesions had a good discriminatory value for detection of ACS during index hospitalization.
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Affiliation(s)
- Maros Ferencik
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Govindaraju K, Badruddin IA, Viswanathan GN, Ramesh SV, Badarudin A. Evaluation of functional severity of coronary artery disease and fluid dynamics' influence on hemodynamic parameters: A review. Phys Med 2012; 29:225-32. [PMID: 22704601 DOI: 10.1016/j.ejmp.2012.03.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 03/19/2012] [Accepted: 03/28/2012] [Indexed: 11/29/2022] Open
Abstract
Coronary Artery Disease (CAD) is responsible for most of the deaths in patients with cardiovascular diseases. Diagnostic coronary angiography analysis offers an anatomical knowledge of the severity of the stenosis. The functional or physiological significance is more valuable than the anatomical significance of CAD. Clinicians assess the functional severity of the stenosis by resorting to an invasive measurement of the pressure drop and flow. Hemodynamic parameters, such as pressure wire assessment fractional flow reserve (FFR) or Doppler wire assessment coronary flow reserve (CFR) are well-proven techniques to evaluate the physiological significance of the coronary artery stenosis in the cardiac catheterization laboratory. Between the two techniques mentioned above, the FFR is seen as a very useful index. The presence of guide wire reduces the coronary flow which causes the underestimation of pressure drop across the stenosis which leads to dilemma for the clinicians in the assessment of moderate stenosis. In such condition, the fundamental fluid mechanics is useful in the development of new functional severity parameters such as pressure drop coefficient and lesion flow coefficient. Since the flow takes place in a narrowed artery, the blood behaves as a non-Newtonian fluid. Computational fluid dynamics (CFD) allows a complete coronary flow simulation to study the relationship between the pressure and flow. This paper aims at explaining (i) diagnostic modalities for the evaluation of the CAD and valuable insights regarding FFR in the evaluation of the functional severity of the CAD (ii) the role of fluid dynamics in measuring the severity of CAD.
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Genders TSS, Ferket BS, Dedic A, Galema TW, Mollet NRA, de Feyter PJ, Fleischmann KE, Nieman K, Hunink MGM. Coronary computed tomography versus exercise testing in patients with stable chest pain: comparative effectiveness and costs. Int J Cardiol 2012; 167:1268-75. [PMID: 22520158 DOI: 10.1016/j.ijcard.2012.03.151] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 02/23/2012] [Accepted: 03/18/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND To determine the comparative effectiveness and costs of a CT-strategy and a stress-electrocardiography-based strategy (standard-of-care; SOC-strategy) for diagnosing coronary artery disease (CAD). METHODS A decision analysis was performed based on a well-documented prospective cohort of 471 outpatients with stable chest pain with follow-up combined with best-available evidence from the literature. Outcomes were correct classification of patients as CAD- (no obstructive CAD), CAD+ (obstructive CAD without revascularization) and indication for Revascularization (using a combination reference standard), diagnostic costs, lifetime health care costs, and quality-adjusted life years (QALY). Parameter uncertainty was analyzed using probabilistic sensitivity analysis. RESULTS For men (and women), diagnostic cost savings were €245 (€252) for the CT-strategy as compared to the SOC-strategy. The CT-strategy classified 82% (88%) of simulated men (women) in the appropriate disease category, whereas 83% (85%) were correctly classified by the SOC-strategy. The long-term cost-effectiveness analysis showed that the SOC-strategy was dominated by the CT-strategy, which was less expensive (-€229 in men, -€444 in women) and more effective (+0.002 QALY in men, +0.005 in women). The CT-strategy was cost-saving (-€231) but also less effective compared to SOC (-0.003 QALY) in men with a pre-test probability of ≥ 70%. The CT-strategy was cost-effective in 100% of simulations, except for men with a pre-test probability ≥ 70% in which case it was 59%. CONCLUSIONS The results suggest that a CT-based strategy is less expensive and equally effective compared to SOC in all women and in men with a pre-test probability <70%.
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Affiliation(s)
- Tessa S S Genders
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Kristensen TS, Kofoed KF, Kühl JT, Nielsen WB, Nielsen MB, Kelbæk H. Prognostic implications of nonobstructive coronary plaques in patients with non-ST-segment elevation myocardial infarction: a multidetector computed tomography study. J Am Coll Cardiol 2011; 58:502-9. [PMID: 21777748 DOI: 10.1016/j.jacc.2011.01.058] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 01/25/2011] [Accepted: 01/31/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVES We sought to determine whether the amount of noncalcified plaque (NCP) in nonobstructive coronary lesions as detected by multidetector computed tomography (MDCT) was a predictor of future coronary events. BACKGROUND Patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI) frequently have multiple coronary plaques, which may be detected with MDCT. METHODS We included 312 consecutive patients presenting with NSTEMI, who underwent 64-slice MDCT coronary angiography and coronary artery calcium scoring before invasive coronary angiography. All patients were treated according to current guidelines based on an invasive treatment approach. Quantitative measurements of plaque composition and volume were performed by MDCT in all nonobstructive coronary lesions. The endpoint was cardiac death, acute coronary syndrome, or symptom-driven revascularization. RESULTS After a median follow-up of 16 months, 23 patients had suffered a cardiac event. Age, male sex, and diabetes mellitus were all associated with an increasing amount of NCP. In a multivariate regression analysis for events, the total amount of NCP in nonobstructive lesions was independently associated with an increased hazard ratio (1.18/100-mm(3) plaque volume increase, p = 0.01). Contrary to this, neither Agatston score nor the amount of calcium in nonobstructive lesions was associated with an increased risk. CONCLUSIONS Multidetector computed tomography plaque imaging identified patients at increased risk of recurrent coronary events after NSTEMI by measuring the total amount of NCP in nonobstructive lesions. The amount of calcified plaque was not associated with an increased risk.
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Affiliation(s)
- Thomas S Kristensen
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen, Denmark.
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Rodés-Cabau J, Gutiérrez M, Courtis J, Larose E, Déry JP, Côté M, Nguyen CM, Gleeton O, Proulx G, Roy L, Noël B, Barbeau G, De Larochellière R, Rinfret S, Bertrand OF. Importance of diffuse atherosclerosis in the functional evaluation of coronary stenosis in the proximal-mid segment of a coronary artery by myocardial fractional flow reserve measurements. Am J Cardiol 2011; 108:483-90. [PMID: 21624549 DOI: 10.1016/j.amjcard.2011.03.073] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 03/25/2011] [Accepted: 03/25/2011] [Indexed: 11/29/2022]
Abstract
The objective of this study was to evaluate the impact of diffuse coronary atherosclerosis on the functional evaluation of moderate coronary lesions in the proximal-mid segment of a coronary artery and its clinical implications. This was a prospective study including 100 consecutive patients with a moderate lesion (45 ± 9% diameter stenosis) in the proximal-mid coronary segment who were evaluated with fractional flow reserve (FFR) measurement. No patient had any other angiographic stenosis distal to the evaluated coronary stenosis. FFR measurements were obtained just distal (~2 to 3 cm) to the lesion (FFR proximal measurement [FFR-PM]) and as distally as possible in the artery (FFR distal measurement [FFR-DM]) after administration of the same dose of intracoronary adenosine. Thirty-nine patients underwent dipyridamole or exercise myocardial single-photon emission computed tomography within 3 months of the FFR study. Mean FFR-PM was significantly higher compared to FFR-DM (0.84 ± 0.08 vs 0.78 ± 0.09, median gradient 0.06, 25th to 75th interquartile range 0.02 to 0.10, p <0.0001). FFR-DM was <0.75 in 33% of patients with FFR-PM ≥0.75, leading to the decision of revascularization in these patients. Performing FFR measurement in the left main/left anterior descending artery predicted a higher gradient between FFR-DM and FFR-PM (odds ratio 4.58, 95% confidence interval 1.4 to 15.03, p = 0.007). FFR-DM exhibited a better correlation with results of myocardial single-photon emission computed tomography compared to FFR-PM (kappa 0.33 vs 0.22, p <0.0001). In conclusion, significant differences between FFR-DM and FFR-PM were observed in patients with moderate coronary stenosis in the proximal-mid segment of a coronary artery, with FFR-DM exhibiting a better correlation with results of noninvasive functional tests. These differences influenced the treatment decision in about 1/3 of patients and highlight the potential clinical relevance of coronary pressure wire positioning for functional evaluation of lesions in the proximal-mid segment of the coronary arteries.
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Affiliation(s)
- Josep Rodés-Cabau
- Interventional Cardiology Laboratories, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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Kolozsvári R, Tar B, Lugosi P, Sánta J, Béres Z, Ungvári T, Polgár P, Kőszegi Z. Plaque volume derived from three-dimensional reconstruction of coronary angiography predicts the fractional flow reserve. Int J Cardiol 2011; 160:140-4. [PMID: 21543127 DOI: 10.1016/j.ijcard.2011.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2010] [Revised: 03/29/2011] [Accepted: 04/14/2011] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To compare the data calculated from the three dimensional (3D) reconstruction of a coronary stenosis with the fractional flow reserve (FFR) values measured on the same coronary segment. METHODS Multiple projections of 22 patients (7 female, 15 male, age: 61 ± 9.73 years) were evaluated by the IC30 software of the Axiom Artis X-ray machine. 3D reconstruction was successfully carried out on 23 coronary arteries (14 LAD, 4 CX and 5 RCA). RESULTS Regression analysis demonstrated significant relationship between the cross-sectional area percentage stenosis (AS) calculated based on the 3D measurement and the FFR (r: -0.566, p: 0.008), as well as between the 3D derived plaque volume (PV) and the FFR (r: -0.501, p: 0.018). On the other hand, the diameter stenosis (DS) and the minimal lumen diameter (MLD) did not correlate with the FFR values. According to the Receiver Operating Characteristic (ROC) analysis the rank of the areas under the ROC curves (AUC) was the following: 1. PV (0.76), 2. AS (0.74), 3. DS (0.62), 4. MLA (0.55), and 5. MLD (0.51). The difference between the AUC of the PV and MLA was found to be significant (p=0.02). The best agreement with the FFR was found when the PV was >44% (sensitivity 66.67%, specificity 82.35%) and the 3D AS was >60% (sensitivity 100%, specificity 47%). CONCLUSION Besides the 3D AS the calculated PV characterizing the entire lesion is also an important predictor of the flow consequence of the stenosis.
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Affiliation(s)
- R Kolozsvári
- Institute of Cardiology, University of Debrecen, Hungary
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van der Bijl N, Geleijns J, Joemai RMS, Bax JJ, Schuijf JD, de Roos A, Kroft LJM. Recent developments in cardiac CT. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/iim.11.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Eid AH, Itani Z, Al-Tannir M, Sayegh S, Samaha A. Primary congenital anomalies of the coronary arteries and relation to atherosclerosis: an angiographic study in Lebanon. J Cardiothorac Surg 2009; 4:58. [PMID: 19874587 PMCID: PMC2775738 DOI: 10.1186/1749-8090-4-58] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Accepted: 10/29/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most coronary artery anomalies are congenital in origin. This study angiographically determined the prevalence of different forms of anomalous aortic origins of coronary anomalies and their anatomic variation in a selected adult Lebanese population. Correlation between these anomalies and stenotic coronary atherosclerotic disease was also investigated. METHODS 4650 coronary angiographies were analyzed for anomalous aortic origin. These anomalies were clustered in four main groups: anomalous left circumflex (LCX) coronary artery, anomalous right coronary artery, anomalous left main coronary artery and anomalous left anterior descending coronary artery. RESULTS Thirty four patients had anomalous aortic origin of coronary arteries. Of these, anomalous LCX coronary artery was the most common (19 of 34 patients). The second most common anomaly was anomalous RCA origin (9 of 34 patients.) The incidence of coronary stenosis in non-anomalous vessels was 50%. However, a significantly smaller percentage (17.46%; 6 of 34 patients) of anomalous vessels exhibited significant stenosis, reminiscent of atherosclerotic disease. Of these six vessels, five were LCX coronary artery arising from right coronary sinus or from early branch of right coronary artery. The sixth was right coronary artery arising from left coronary sinus. CONCLUSION The incidence of congenital coronary anomalies in Lebanon is similar to other populations where the most common is the LCX coronary artery. Isolated congenital coronary anomalies do not increase the risk of developing coronary stenosis or atherosclerosis. Angiographic detection of these anomalies is clinically important for coronary angioplasty or cardiac surgery.
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Affiliation(s)
- Ali H Eid
- Department of Biology, College of Science, United Arab Emirates University, Al-Ain, UAE.
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