Quantitative baseline CT plaque characterization of unrevascularized non-culprit intermediate coronary stenosis predicts lesion volume progression and long-term prognosis: A serial CT follow-up study

Prognostic value of serial coronary computed tomography angiography-derived perivascular fat-attenuation index and plaque volume in patients with suspected coronary artery disease

AIMS

To investigate the prognostic value of serial coronary computed tomography angiography (CCTA) derived plaque information, fractional flow reserve (CT-FFR), and perivascular fat-attenuation index (FAI) on major adverse cardiac events (MACE) in patients with suspected coronary artery disease.

MATERIALS AND METHODS

A total of 252 patients who underwent serial CCTA between January 2018 and December 2021 and were followed until June 2022. MACE were recorded. The analysis indexes included percent diameter stenosis (%DS), lesion length, plaque volume, CT-FFR, and FAI, with an emphasis on their changes between the baseline and follow-up CCTAs. Multivariate regression analysis were employed to identify independent risk factors for MACE.

RESULTS

After a median follow-up of 48-month, MACE occurred in 32 patients (12.7%). Patients with MACE displayed more severe stenosis, longer lesions, and larger plaque volumes in both baseline and follow-up CCTAs compared with no-MACE patients (all P<0.05). Patients with MACE displayed more severe stenosis, longer lesion, and larger plaque volume in both baseline and follow-up CCTAs compared with no-MACE patients. In addition, MACE patients also showed lower CT-FFR and higher △CT-FFR. Although FAI was significantly higher in MACE patients at baseline CCTA, FAI was notably increased in MACE patients, and decreased in the no-MACE patients (all P<0.05). Logistic regression analysis showed that ΔFAI, %DS, and plaque volume were independent predictors of MACE, with ΔFAI being the most significant (OR: 16.725, P<0.000). A multivariable model showed a significantly improved C-index of 0.903 (95% confidence interval: 0.836-0.970) for MACE prediction, when compared with single index alone.

CONCLUSIONS

Serial CCTA-derived ΔFAI, %DS, and plaque volume are crucial independent predictors of MACE in patients with suspected coronary artery disease, highlighting the importance of CCTA in patient risk stratification and prognostic assessment.

Automatic Quantification of Local Plaque Thickness Differences as Assessed by Serial Coronary Computed Tomography Angiography Using Scan-Quality-Based Vessel-Specific Thresholds

INTRODUCTION

The use of serial coronary computed tomography angiography (CCTA) allows for the early assessment of coronary plaque progression, a crucial factor in averting major adverse cardiac events (MACEs). Traditionally, serial CCTA is assessed using anatomical landmarks to match baseline and follow-up scans. Recently, a tool has been developed that allows for the automatic quantification of local plaque thickness differences in serial CCTA utilizing plaque contour delineation. The aim of this study was to determine thresholds of plaque thickness differences that define whether there is plaque progression and/or regression. These thresholds depend on the contrast-to-noise ratio (CNR).

METHODS

Plaque thickness differences between two scans acquired at the same moment in time should always be zero. The negative and positive differences in plaque contour delineation in these scans were used along with the CNR in order to create calibration graphs on which a linear regression analysis was performed. This analysis was conducted on a cohort of 50 patients referred for a CCTA due to chest complaints. A total of 300 coronary vessels were analyzed. First, plaque contours were semi-automatically determined for all major epicardial coronary vessels. Second, manual drawings of seven regions of interest (ROIs) per scan were used to quantify the scan quality based on the CNR for each vessel.

RESULTS

A linear regression analysis was performed on the CNR and negative and positive plaque contour delineation differences. Accounting for the standard error of the estimate, the linear regression analysis revealed that above 1.009 - 0.002 × CNR there is an increase in plaque thickness (progression), and below - 1.638 + 0.012 × CNR there is a decrease in plaque thickness (regression).

CONCLUSION

This study demonstrates the feasibility of developing vessel-specific, quality-based thresholds for visualizing local plaque thickness differences evaluated by serial CCTA. These thresholds have the potential to facilitate the early detection of atherosclerosis progression.

No evidence of coronary plaque stabilization by allopurinol in patients with acute coronary syndrome

BACKGROUND

Allopurinol, a xanthine inhibitor that lowers uric acid concentration, has been proven to reduce inflammation and oxidative stress in patients with cardiovascular disease. However, it is unknown whether these beneficial effects translate into favorable plaque modification in acute coronary syndromes (ACS). This study aimed to investigate whether allopurinol could improve coronary plaque stabilization using coronary computed tomography angiography (CCTA).

METHODS

This was a prospective, single-center, randomized, double-blind clinical trial began in March 2019. A total of 162 ACS patients aged 18-80 years with a blood level of high-sensitivity C-reactive protein (hsCRP) ​> ​2 ​mg/L were included. The subjects were randomly assigned in a 1:1 ratio to receive either allopurinol sustained-release capsules (at a dose of 0.25 ​g once daily) or placebo for 12 months. The plaque analysis was performed at CCTA. The primary efficacy endpoint was the change in low-attenuation plaque volume (LAPV) from baseline to the 12-month follow-up.

RESULTS

Among 162 patients, 54 in allopurinol group and 51 in placebo group completed the study. The median follow-up duration was 14 months in both groups. Compared with placebo, allopurinol therapy did not significantly alter LAPV (-13.4 ​± ​3.7 ​% vs. -17.8 ​± ​3.6 ​%, p ​= ​0.390), intermediate attenuation plaque volume (-16.1 ​± ​3.0 ​% vs. -16.2 ​± ​2.9 ​%, p ​= ​0.992), dense calcified plaque volume (12.2 ​± ​13.7 ​% vs. 9.7 ​± ​13.0 ​%, p ​= ​0.894), total atheroma volume (-15.2 ​± ​3.2 ​% vs. -16.4 ​± ​3.1 ​%, p ​= ​0.785), remodeling index (2.0 ​± ​3.9 ​% vs. 5.4 ​± ​3.8 ​%, p ​= ​0.536) or hsCRP levels (-73.6 [-91.6-17.9] % vs. -81.2 [-95.4-47.7] %, p ​= ​0.286).

CONCLUSIONS

Our findings suggest that allopurinol does not improve atherosclerotic plaque stability or inflammation in ACS.

Role of Cardiovascular Imaging in Risk Assessment: Recent Advances, Gaps in Evidence, and Future Directions

Optimal risk assessment for primary prevention remains highly challenging. Recent registries have highlighted major discrepancies between guidelines and daily practice. Although guidelines have improved over time and provide updated risk scores, they still fail to identify a significant proportion of at-risk individuals, who then miss out on effective prevention measures until their initial ischemic events. Cardiovascular imaging is progressively assuming an increasingly pivotal role, playing a crucial part in enhancing the meticulous categorization of individuals according to their risk profiles, thus enabling the customization of precise therapeutic strategies for patients with increased cardiovascular risks. For the most part, the current approach to patients with atherosclerotic cardiovascular disease (ASCVD) is homogeneous. However, data from registries (e.g., REACH, CORONOR) and randomized clinical trials (e.g., COMPASS, FOURIER, and ODYSSEY outcomes) highlight heterogeneity in the risks of recurrent ischemic events, which are especially higher in patients with poly-vascular disease and/or multivessel coronary disease. This indicates the need for a more individualized strategy and further research to improve definitions of individual residual risk, with a view of intensifying treatments in the subgroups with very high residual risk. In this narrative review, we discuss advances in cardiovascular imaging, its current place in the guidelines, the gaps in evidence, and perspectives for primary and secondary prevention to improve risk assessment and therapeutic strategies using cardiovascular imaging.

Plaque progression at coronary CT angiography links non-alcoholic fatty liver disease and cardiovascular events: a prospective single-center study

OBJECTIVES

The presence of non-alcoholic fatty liver disease (NAFLD) has been associated with major adverse cardiovascular events (MACEs); however, the mechanisms that initiate the risk for MACEs in patients with NAFLD remain unknown. We sought to investigate whether plaque progression (PP), determined by coronary CT angiography (CCTA), moderate the relationship between NAFLD and MACEs.

METHODS

A total of 1683 asymptomatic participants (mean age, 63.3 ± 9.4 [range, 38-85] years; 1117 men) who underwent baseline and follow-up CCTA examination were prospectively included in our study. All of the participants were divided into the NAFLD and non-NAFLD groups. PP was determined by follow-up CCTA. The primary endpoint was MACEs, defined as the composite of all-cause death, nonfatal myocardial infarction, and unplanned hospitalization for acute coronary syndrome leading to revascularization.

RESULTS

At follow-up CCTA, participants with NAFLD showed higher incidence of PP than those without [33.0% (248/752) vs. 16.6% (155/931), p < 0.001]. Compared with non-NAFLD participants, participants with NAFLD had a lower 9.7-year event-free survival rate (80.9 vs. 66.4%, log-rank p < 0.001). Cox regression analysis revealed NAFLD was significantly associated with MACEs (HR = 1.63, 95% CI: 1.28 to 2.06, p < 0.001) after adjusting for covariables. However, this association was no longer significant after adjustment for PP (HR = 1.10, 95% CI: 0.84 to 1.45, p = 0.496). The mediation analysis revealed that PP had a significant indirect effect (β = 0.0587, 95% CI: 0.0424 to 0.08, p < 0.001) and mediated 99.8% (p = 0.002) for the relationship between NAFLD and MACEs.

CONCLUSIONS

Plaque progression, identified by follow-up CCTA, mediates the relationship between NAFLD and MACEs.

KEY POINTS

The incidence of CCTA-identified PP was higher for participants with NAFLD than those without NAFLD (248/752 [33.0%] vs. 155/931 [16.6%], p < 0.001). Participants with NAFLD had a lower 9.7-year event-free survival rate than those without NAFLD (66.4% vs. 80.9%, log-rank p < 0.001). The mediation analysis revealed that PP had a significant indirect effect (β = 0.0587, 95% CI: 0.0424 to 0.08, p < 0.001) and mediated 99.8% (p = 0.002) for the relationship between NAFLD and MACEs.

Utilizing (serial) coronary computed tomography angiography (CCTA) to predict plaque progression and major adverse cardiac events (MACE): results, merits and challenges

OBJECTIVES

To present an overview of studies using serial coronary computed tomography angiography (CCTA) as a tool for finding both quantitative (changes) and qualitative plaque characteristics as well as epicardial adipose tissue (EAT) volume changes as predictors of plaque progression and/or major adverse cardiac events (MACE) and outline the challenges and advantages of using a serial non-invasive imaging approach for assessing cardiovascular prognosis.

METHODS

A literature search was performed in PubMed, Embase, Web of Science, Cochrane Library and Emcare. All observational cohort studies were assessed for quality using the Newcastle-Ottawa Scale (NOS). The NOS score was then converted into Agency for Healthcare Research and Quality (AHRQ) standards: good, fair and poor.

RESULTS

A total of 36 articles were analyzed for this review, 3 of which were meta-analyses and one was a technical paper. Quantitative baseline plaque features seem to be more predictive of MACE and/or plaque progression as compared to qualitative plaque features.

CONCLUSIONS

A critical review of the literature focusing on studies utilizing serial CCTA revealed that mainly quantitative baseline plaque features and quantitative plaque changes are predictive of MACE and/or plaque progression contrary to qualitative plaque features. Significant questions regarding the clinical implications of these specific quantitative and qualitative plaque features as well as the challenges of using serial CCTA have yet to be resolved in studies using this imaging technique.

KEY POINTS

• Use of (serial) CCTA can identify plaque characteristics and plaque changes as well as changes in EAT volume that are predictive of plaque progression and/or major adverse events (MACE) at follow-up. • Studies utilizing serial CCTA revealed that mainly quantitative baseline plaque features and quantitative plaque changes are predictive of MACE and/or plaque progression contrary to qualitative plaque features. • Ultimately, serial CCTA is a promising technique for the evaluation of cardiovascular prognosis, yet technical details remain to be refined.

Long-term prognostic value of the serial changes of CT-derived fractional flow reserve and perivascular fat attenuation index

BACKGROUND

To investigate the serial changes of computed tomography (CT) fractional flow reserve (CT-FFR) and fat attenuation index (FAI), and explore their relationships with long-term clinical outcomes.

METHODS

Consecutive symptomatic patients with an intermediate pretest probability of coronary artery disease 1-4 were prospectively enrolled if coronary CT angiography (CCTA) revealed at least 1 lesion with 30-70% stenosis on major epicardial arteries. Follow-up CCTA was performed at 1 to 1.5-year intervals. All patients were further followed up after the second CCTA until September 2019. The Coronary Artery Disease - Reporting and Data System (CAD-RADS) grade, high-risk plaque features, lesion-specific CT-FFR, and FAI were measured for prognosis analysis.

RESULTS

A total of 263 patients were included in the analysis, and 38 major adverse cardiac events (MACEs) occurred. In the MACE group, the lesion-specific CT-FFR decreased significantly at the follow-up CCTA [0.80 (0.74-0.90) versus 0.85 (0.76-0.93); P=0.01], whereas the FAI did not notably increase (-70.4±8.9 versus -71.3±7.1 HU; P=0.436). In the non-MACE group, lesion-specific CT-FFR increased markedly [0.91 (0.84-0.95) versus 0.90 (0.82-0.94); P<0.001], while the FAI decreased substantially (-74.0±10.8 versus -72.4±11.5 HU; P=0.004). Decreased CT-FFR (adjusted overall hazard ratio =2.455; P=0.023) and increased FAI (adjusted hazard ratio =2.956; P=0.002) were the strongest independent predictors of MACEs. Serial changes of CT-FFR and FAI provided incremental prognostic value (Concordance statistic =0.716; P=0.003; over conventional clinical and imaging parameters (Concordance statistic =0.762; P=0.004).

CONCLUSIONS

Decreased CT-FFR and increased FAI at follow-up CCTA were the 2 strongest predictors of MACEs. Serial changes of CT-FFR and FAI provided incremental prognostic value over conventional clinical and imaging parameters for risk stratification. In addition, decreased CT-FFR provided incremental predictive value for MACEs from 15 months after second CCTA, while increased FAI added prognostic value from the second CCTA onwards.

Lipoprotein(a) is associated with coronary atheroma progression: analysis from a serial coronary computed tomography angiography study

BACKGROUND

Lipoprotein(a) [Lp(a)] has been closely related to coronary atherosclerosis and might affect perivascular inflammation due to its proinflammatory properties. However, there are limited data about Lp(a) and related perivascular inflammation on coronary atheroma progression. Therefore, this study aimed to investigate the associations between Lp(a) and the perivascular fat attenuation index (FAI) with coronary atheroma progression detected by coronary computed tomography angiography (CCTA).

METHODS

Patients who underwent serial CCTA examinations without a history of revascularization and with available data for Lp(a) within one month before or after baseline and follow-up CCTA imaging scans were considered to be included. CCTA quantitative analyses were performed to obtain the total plaque volume (TPV) and the perivascular FAI. Coronary plaque progression (PP) was defined as a ≥ 10% increase in the change of the TPV at the patient level or the presence of new-onset coronary atheroma lesions. The associations between Lp(a) or the perivascular FAI with PP were examined by multivariate logistic regression.

RESULTS

A total of 116 patients were ultimately enrolled in the present study with a mean CCTA interscan interval of 30.80 ± 13.50 months. Among the 116 patients (mean age: 53.49 ± 10.21 years, males: 83.6%), 32 patients presented PP during the follow-up interval. Lp(a) levels were significantly higher among PP patients than those among non-PP patients at both baseline [15.80 (9.09-33.60) mg/dLvs. 10.50 (4.75-19.71) mg/dL,P = 0.029] and follow-up [20.60 (10.45-34.55) mg/dLvs. 8.77 (5.00-18.78) mg/dL,P = 0.004]. However, there were no differences in the perivascular FAI between PP group and non-PP group at either baseline or follow-up. Multivariate logistic regression analysis showed that elevated baseline Lp(a) level (OR = 1.031, 95% CI: 1.005-1.058,P = 0.019) was an independent risk factor for PP after adjustment for other conventional variables.

CONCLUSIONS

Lp(a) was independently associated with coronary atheroma progression beyond low-density lipoprotein cholesterol and other conventional risk factors. Further studies are warranted to identify the inflammation effect exhibited as the perivascular FAI on coronary atheroma progression.

CAD-RADS may underestimate coronary plaque progression as detected by serial CT angiography

Aims

We wished to assess whether different clinical definitions of coronary artery disease (CAD) [segment stenosis and involvement score (SSS, SIS), Coronary Artery Disease—Reporting and Data System (CAD-RADS)] affect which patients are considered to progress and which risk factors affect progression.

Methods and results

We enrolled 115 subsequent patients (60.1 ± 9.6 years, 27% female) who underwent serial coronary computed tomography angiography (CTA) imaging with >1year between the two examinations. CAD was described using SSS, SIS, and CAD-RADS. Linear mixed models were used to investigate the effects of risk factors on the overall amount of CAD and the effect on annual progression rate of different definitions. Coronary plaque burdens were SSS 4.63 ± 4.06 vs. 5.67 ± 5.10, P < 0.001; SIS 3.43 ± 2.53 vs. 3.89 ± 2.65, P < 0.001; CAD-RADS 0:8.7% vs. 0.0% 1:44.3% vs. 40.9%, 2:34.8% vs. 40.9%, 3:7.0% vs. 9.6% 4:3.5% vs. 6.1% 5:1.7% vs. 2.6%, P < 0.001, at baseline and follow-up, respectively. Overall, 53.0%, 29.6%, and 28.7% of patients progressed over time based on SSS, SIS, and CAD-RADS, respectively. Of the patients who progressed based on SSS, only 54% showed changes in CAD-RADS. Smoking and diabetes increased the annual progression rate of SSS by 0.37/year and 0.38/year, respectively (both P < 0.05). Furthermore, each year increase in age raised SSS by 0.12 [confidence interval (CI) 0.05–0.20, P = 0.001] and SIS 0.10 (CI 0.06–0.15, P < 0.001), while female sex was associated with 2.86 lower SSS (CI −4.52 to −1.20, P < 0.001) and 1.68 SIS values (CI −2.65 to −0.77, P = 0.001).

Conclusion

CAD-RADS could not capture the progression of CAD in almost half of patients with serial CTA. Differences in CAD definitions may lead to significant differences in patients who are considered to progress, and which risk factors are considered to influence progression.

Low attenuation plaque volume on coronary computed tomography angiography is associated with plaque progression

BACKGROUND

Patient-related clinical factors, laboratory factors, and some imaging factors may lead to statistical bias when investigating coronary plaque progression. In this study, we avoided patient characteristics by comparing morphological characteristics of plaque progression and nonprogression within the same patient with multiple plaques.

METHODS

From August 2011 to December 2018, 177 consecutive patients with 424 plaques who were followed with coronary computed tomography angiography (CTA) were reviewed retrospectively. Follow-up images of the plaques were used to determine whether the plaque volume or stenosis grade increased. The plaques were divided into progressive and nonprogressive groups. Logistic regression analysis was used to identify the factors associated with plaque progression. Through clinical follow-up, we analyzed whether the factors associated with plaque progression were related to major adverse cardiac events (MACEs).

RESULTS

There were 223 plaques that progressed during a mean follow-up period of 27.6 ± 15.9 months. The univariate logistic regression model revealed that only low attenuation plaque (LAP) volume (P = 0.02) was associated with plaque progression. After a mean post-CTA follow-up period of 36.7 ± 18.4 months, 37 patients experienced MACEs, and LAP volume was significantly related to future MACEs.

CONCLUSION

Only a high baseline LAP volume was associated with plaque progression, and patients with progressive plaques and a high LAP volume were more likely to have future MACEs. More attention should be given to plaques with LAP volumes larger than 2.4 mm3.

Prognostic value of CT-derived myocardial blood flow, CT fractional flow reserve and high-risk plaque features for predicting major adverse cardiac events

Background

Myocardial blood flow (MBF), CT fractional flow reserve (CT-FFR) and high-risk plaque (HRP) features have been revealed to be associated with patients' prognosis. However, direct intra-individual comparison of these CT-derived parameters has not been explored yet. The aim of this study was to investigate the prognostic value of CT-derived MBF, CT-FFR and HRP features for predicting major adverse cardiac events (MACEs).

Methods

Consecutive patients with chest pain and intermediate-to-high pre-test probability of coronary artery disease (CAD) were prospectively enrolled. All patients were referred for dynamic CT myocardial perfusion imaging (CT-MPI) + coronary CT angiography (CCTA) and followed up for at least 1 year. MBF_ischemic (mean MBF of all ischemic segments), MBF_ratio (MBF of ischemic segments/MBF of reference segments), CT-FFR and HRP features were measured and multivariate analysis was used to evaluate the predictive value of all above parameters for MACEs.

Results

One hundred and forty-two patients were included into final analysis. MBF_ischemic and MBF_ratio was significantly lower in patients with MACE compared to patients without MACE (87 vs. 153 mL/100 mL/min and 0.64 vs. 0.95, both P<0.001). Similarly, CT-FFR was also markedly lower in patients with MACE (0.58 vs. 0.88, P<0.001) whereas coronary artery calcium score (CACS) was significantly higher (1,038.9 vs. 34.2, P<0.001). According to ROC curve analysis, MBF_ischemic, MBF_ratio and CACS had largest area under curve (AUC =0.872, 0.855 and 0.813 respectively, all P<0.001) for identifying patients with MACE. After adjusted by multivariate analysis, MBF_ischemic (hazard ratio =23.382, P=0.003) and CACS (hazard ratio =3.759, P=0.029) were revealed to be the independent predictors for MACE where CT-FFR and HRP features failed to have prognostic value.

Conclusions

MBF_ischemic derived from dynamic CT-MPI was the strongest predictor for MACE, followed by CACS. MBF_ischemic outperformed HRP features and CT-FFR for prediction of unfavorable clinical outcome.

Combined coronary CT angiography with plain scan for diagnosis of ruptured plaque: comparison with optical coherence tomography

To evaluate the diagnostic efficacy of CCTA + plain scan for ruptured plaques, with optical coherence tomography (OCT) as the reference, and to provide preliminary analysis of influential factors. Patients who underwent CCTA and OCT were retrospectively enrolled. The diagnostic standards for ruptured plaque on CCTA + plain scan were ulcer or intra-plaque dye penetration on CCTA, and a careful review of images from the plain scans to ensure areas of them were not calcification. The diagnosis of ruptured plaque was made by OCT. Total 65 patients with 71 plaques were included. There were 40 OCT-confirmed ruptured plaques in 38 patients and 31 OCT-confirmed non-ruptured plaques in 27 patients. CCTA + plain scan identified 27 ruptured plaques in 27 patients and 28 non-ruptured plaques in 24 patients. With OCT as the gold standard, the per-patient sensitivity, specificity, positive and negative predictive values, and accuracy of CCTA + plain scan for diagnosing ruptured plaque were 71%, 89%, 90%, 69%, and 78%, and there was good agreement (Kappa = 0.70) between CCTA + plain scan and OCT. Among 13 false negative ruptured plaques, 2 had calcifications close to the rupture, and the cavity depth in the remaining 11 was 0.46 ± 0.17 mm, versus 0.98 ± 0.26 mm in 27 true positive ruptured plaques (P < 0.01). CCTA + plain scan may identify morphological features of ruptured plaques. The cavity depth of the ruptured plaques and calcification at the rupture site seem major factors influencing the diagnostic accuracy for plaque rupture. Future perspective studied are needed to confirm these preliminary findings.

Predictive value of spiral shape in coronary plaque progression: an intraindividual comparative study

OBJECTIVE

We conducted a pilot study to explore the value of spiral-shaped sign of plaque from coronary computed tomographic angiography (CCTA) in predicting plaque progression by intraindividual comparison.

METHODS

A total of 30 patients with a total of 60 plaques who received serial CCTA were retrospectively included and intraindividual compared. The spiral shape was defined as plaques coursing along the long axis of a coronary artery and encircling it at an angle of ≥ 180 degrees. The high-risk and other plaque signs were recorded.

RESULTS

On baseline CCTA, the spiral shape (P < 0.01) and length (P < 0.05) of plaques were more frequently seen in the progression group than in the nonprogression group; however, there was no difference between two groups in terms of high-risk plaque signs. In the progression group, plaque length, volume, and napkin-ring sign on follow-up CCTA were significantly greater than at baseline (P < 0.05). In the nonprogression group, there were fewer low-attenuation and positive remodeling plaques on follow-up CCTA than at baseline (P < 0.05). The spiral shape (standardized β = -4.55; P < 0.01) was an independent risk factor for plaque progression. There were 24 spiral plaques in the progression group, of which 16 (66.7%) had progression below the twist point of the spiral shape.

CONCLUSIONS

The baseline spiral shape is more frequently found in those lesions that progress than in those that do not in patients with multiple coronary lesions, and the spiral shape is an independent predictor of which plaques will progress.

Impacts of smoking status on the clinical outcomes of coronary non-target lesions in patients with coronary heart disease: a single-center angiographic study

Background

Coronary atherosclerotic plaque could go through rapid progression and induce adverse cardiac events. This study aimed to evaluate the impacts of smoking status on clinical outcomes of coronary non-target lesions.

Methods

Consecutive patients with coronary heart disease who underwent two serial coronary angiographies were included. All coronary non-target lesions were recorded at first coronary angiography and analyzed using quantitative coronary angiography at both procedures. Patients were grouped into non-smokers, quitters, and smokers according to their smoking status. Clinical outcomes including rapid lesion progression, lesion re-vascularization, and myocardial infarction were recorded at second coronary angiography. Multivariable Cox regression analysis was used to investigate the association between smoking status and clinical outcomes.

Results

A total of 1255 patients and 1670 lesions were included. Smokers were younger and more likely to be male compared with non-smokers. Increase in percent diameter stenosis was significantly lower (2.7 [0.6, 7.1] % vs. 3.5 [0.9, 8.9]%) and 3.4 [1.1, 7.7]%, P = 0.020) in quitters than those in smokers and non-smokers. Quitters tended to have a decreased incidence of rapid lesions progression (15.8% [76/482] vs. 21.6% [74/342] and 20.6% [89/431], P = 0.062), lesion re-vascularization (13.1% [63/482] vs. 15.5% [53/432] and 15.5% [67/431], P = 0.448), lesion-related myocardial infarction (0.8% [4/482] vs. 2.6% [9/342] and 1.4% [6/431], P = 0.110) and all-cause myocardial infarction (1.9% [9/482] vs. 4.1% [14/342] and 2.3% [10/431], P = 0.128) compared with smokers and non-smokers. In multivariable analysis, smoking status was not an independent predictor for rapid lesion progression, lesion re-vascularization, and lesion-related myocardial infarction except that a higher risk of all-cause myocardial infarction was observed in smokers than non-smokers (hazards ratio: 3.00, 95% confidence interval: 1.04–8.62, P = 0.042).

Conclusion

Smoking cessation mitigates the increase in percent diameter stenosis of coronary non-target lesions, meanwhile, smokers are associated with increased risk for all-cause myocardial infarction compared with non-smokers.

Epicardial adipose tissue characteristics and CT high-risk plaque features: correlation with coronary thin-cap fibroatheroma determined by intravascular ultrasound

To investigate the correlation of epicardial adipose tissue (EAT) characteristics and high-risk plaque features characterized by coronary CT angiography (CCTA) for identifying the presence of thin-cap fibroatheroma (TCFA). Patients who underwent both CCTA and intravascular ultrasound (IVUS) within 4 weeks were retrospectively included. CT-derived quantitative and qualitative parameters, including diameter stenosis, low attenuation plaque (LAP), napkin-ring sign (NRS), positive remodeling and spotty calcification, were recorded. EAT volume and density were also measured. TCFA lesions and non-TCFA lesions were determined by IVUS. Multivariate regression analysis was used to determine the independent predictors of TCFA lesions. Sixty-eight patients (mean age: 68.6 ± 9.7 years; 40 males) with 91 lesions were finally included in our study. For CT-derived plaque features, LAP (77.8% versus 25%, p < 0.001) and NRS (40.7% versus 9.4%, p < 0.001) was more frequently presented in TCFA lesions than was in non-TCFA lesions. For EAT characteristics, EAT volume (110 ± 14 cm³ versus 98 ± 12 cm³, p < 0.001) was significantly larger whereas EAT density (-77 ± 4 HU versus -80 ± 5, p = 0.003) was markedly higher in TCFA lesions. According to multivariate logistic regression analysis, LAP, EAT volume and EAT density were significant predictors (odds ratio: 9.758, 1.095 and 1.202, all p value < 0.05) for the presence of TCFA lesions. EAT volume and density was greater in patients with TCFA lesions whereas LAP and NRS was more frequently presented. In addition, EAT characteristics and LAP were independent predictors of vulnerable plaques as determined by IVUS.

[Prognosis of patients with vulnerable plaques indicated by coronary CT angiography]

OBJECTIVE

To investigate the prognosis of patients with vulnerable plaque indicated by coronary CT angiography (CCTA).

METHODS

Totally 1963 patients underwent CCTA from February 2nd 2015 to September 13th 2015, and 2728 coronary borderline lesions (stenosis of 50%-70%) were detected. Among them 804 patients had vulnerable plaques and 1159 patients had stable plaques. The primary endpoint was major cardiac adverse events (MACE), including cardiac death, acute myocardial infarction and target lesion revascularization.

RESULTS

Patients were followed up for a mean follow-up of 27.4±2.3 months. The incidence of MACE in the vulnerable plaque group was significantly higher than that in the stable plaque group (10.8%vs 2.3%, P &lt; 0.01). After adjusting for age, gender, smoking, hypertension, diabetes, hyperlipidemia, the MACE hazard ratio (HR) in the vulnerable plaque group was 5.022 (95% CI:3.254-7.751, P &lt; 0.01).Subgroup analysis showed that in the vulnerable plaque group, the incidence of MACE in patients taking antiplatelet and statin ≤3 months and those taking antiplatelet and statin &gt; 3 months was 17.0%and 5.8%, respectively (HR=3.149, 95% CI:1.987-4.992, P &lt; 0.01); but the difference did not seen in stable plaque group (HR=1.721, 95% CI:0.798-3.712, P&gt;0.05).

CONCLUSIONS

This study confirmed the risk of MACE in patients with vulnerable plaque detected by CCTA and the drug treatment may reduce the risk for patients with vulnerable plaque.

The value of quantified plaque analysis by dual-source coronary CT angiography to detect vulnerable plaques: a comparison study with intravascular ultrasound

Background

To investigate the diagnostic performance of quantified plaque analysis and high-risk plaque characterization by coronary computed tomography angiography (CCTA) for identifying thin-cap fibroatheroma (TCFA).

Methods

Patients who underwent both CCTA and intravascular ultrasound (IVUS) within 4 weeks were retrospectively included. CT-derived quantitative and qualitative parameters, including diameter stenosis, minimal lumen area (MLA), low attenuation plaque (LAP) volume napkin-ring sign (NRS), positive remodeling (PR) and spotty calcification, were recorded. TCFA lesions and non-TCFA lesions were determined by IVUS. Multivariate regression analysis was used to determine the independent predictors of TCFA lesions.

Results

Sixty-five patients (mean age: 69.8±9.2 years, 29 females) with 89 lesions were finally included. LAP and NRS were more frequently presented in the group of TCFA lesions. The mean LAP volume of TCFA lesions was significantly larger than that of non-TCFA lesions [16.5 (11.0-23.0) vs. 0 (0-1.5) mm³, P<0.001]. According to multivariate logistic regression analysis, LAP volume was the only significant predictor for IVUS-confirmed vulnerable plaques (odds ratio =3.294, 95% confidence interval: 1.177-9.223, P=0.023). LAP volume showed largest area under curve (AUC) for diagnosing TCFA lesions (AUC =0.901, 95% confidence interval: 0.819-0.954, P<0.0001). When using >8 mm³ as the best cutoff value, the diagnostic accuracy, sensitivity and specificity of LAP volume for predicting TCFA lesions were 91.0% (81/89), 84.6% (22/26) and 96.8% (61/63) respectively.

Conclusions

CT-derived LAP volume of TCFA lesions was significantly higher than those of non-TCFA lesions. LAP volume was the strongest predictor for TCFA lesions as validated by IVUS.

The best predictor of ischemic coronary stenosis: subtended myocardial volume, machine learning-based FFRCT, or high-risk plaque features?

OBJECTIVES

The present study aimed to compare the diagnostic performance of a machine learning (ML)-based FFR_CT algorithm, quantified subtended myocardial volume, and high-risk plaque features for predicting if a coronary stenosis is hemodynamically significant, with reference to FFR_ICA.

METHODS

Patients who underwent both CCTA and FFR_ICA measurement within 2 weeks were retrospectively included. ML-based FFR_CT, volume of subtended myocardium (V_sub), percentage of subtended myocardium volume versus total myocardium volume (V_ratio), high-risk plaque features, minimal lumen diameter (MLD), and minimal lumen area (MLA) along with other parameters were recorded. Lesions with FFR_ICA ≤ 0.8 were considered to be functionally significant.

RESULTS

One hundred eighty patients with 208 lesions were included. The lesion length (LL), diameter stenosis, area stenosis, plaque burden, V_sub, V_ratio, V_ratio/MLD, V_ratio/MLA, and LL/MLD⁴ were all significantly longer or larger in the group of FFR_ICA ≤ 0.8 while smaller minimal lumen area, MLD, and FFR_CT value were noted. The AUC of FFR_CT + V_ratio/MLD was significantly better than that of FFR_CT alone (0.935 versus 0.873, p < 0.001). High-risk plaque features failed to show difference between functionally significant and insignificant groups. V_ratio/MLD-complemented ML-based FFR_CT for "gray zone" lesions with FFR_CT value ranged from 0.7 to 0.8 and the combined use of these two parameters yielded the best diagnostic performance (86.5%, 180/208).

CONCLUSIONS

ML-based FFR_CT simulation and V_ratio/MLD both provide incremental value over CCTA-derived diameter stenosis and high-risk plaque features for predicting hemodynamically significant lesions. V_ratio/MLD is more accurate than ML-based FFR_CT for lesions with simulated FFR_CT value from 0.7 to 0.8.

KEY POINTS

• Machine learning-based FFR _CT and subtended myocardium volume both performed well for predicting hemodynamically significant coronary stenosis. • Subtended myocardium volume was more accurate than machine learning-based FFR _CT for "gray zone" lesions with simulated FFR value from 0.7 to 0.8. • CT-derived high-risk plaque features failed to correctly identify hemodynamically significant stenosis.