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Jonas RA, Weerakoon S, Fisher R, Griffin WF, Kumar V, Rahban H, Marques H, Karlsberg RP, Jennings RS, Crabtree TR, Choi AD, Earls JP. Interobserver variability among expert readers quantifying plaque volume and plaque characteristics on coronary CT angiography: a CLARIFY trial sub-study. Clin Imaging 2022; 91:19-25. [PMID: 35986973 DOI: 10.1016/j.clinimag.2022.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/21/2022] [Accepted: 08/07/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The difference between expert level (L3) reader and artificial intelligence (AI) performance for quantifying coronary plaque and plaque components is unknown. OBJECTIVE This study evaluates the interobserver variability among expert readers for quantifying the volume of coronary plaque and plaque components on coronary computed tomographic angiography (CCTA) using an artificial intelligence enabled quantitative CCTA analysis software as a reference (AI-QCT). METHODS This study uses CCTA imaging obtained from 232 patients enrolled in the CLARIFY (CT EvaLuation by ARtificial Intelligence For Atherosclerosis, Stenosis and Vascular MorphologY) study. Readers quantified overall plaque volume and the % breakdown of noncalcified plaque (NCP) and calcified plaque (CP) on a per vessel basis. Readers categorized high risk plaque (HRP) based on the presence of low-attenuation-noncalcified plaque (LA-NCP) and positive remodeling (PR; ≥1.10). All CCTAs were analyzed by an FDA-cleared software service that performs AI-driven plaque characterization and quantification (AI-QCT) for comparison to L3 readers. Reader generated analyses were compared among readers and to AI-QCT generated analyses. RESULTS When evaluating plaque volume on a per vessel basis, expert readers achieved moderate to high interobserver consistency with an intra-class correlation coefficient of 0.78 for a single reader score and 0.91 for mean scores. There was a moderate trend between readers 1, 2, and 3 and AI with spearman coefficients of 0.70, 0.68 and 0.74, respectively. There was high discordance between readers and AI plaque component analyses. When quantifying %NCP v. %CP, readers 1, 2, and 3 achieved a weighted kappa coefficient of 0.23, 0.34 and 0.24, respectively, compared to AI with a spearman coefficient of 0.38, 0.51, and 0.60, respectively. The intra-class correlation coefficient among readers for plaque composition assessment was 0.68. With respect to HRP, readers 1, 2, and 3 achieved a weighted kappa coefficient of 0.22, 0.26, and 0.17, respectively, and a spearman coefficient of 0.36, 0.35, and 0.44, respectively. CONCLUSION Expert readers performed moderately well quantifying total plaque volumes with high consistency. However, there was both significant interobserver variability and high discordance with AI-QCT when quantifying plaque composition.
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Affiliation(s)
- Rebecca A Jonas
- Department of Internal Medicine, Thomas Jefferson University Medical Center, Philadelphia, PA, USA
| | - Shaneke Weerakoon
- Department of Cardiology, The George Washington University School of Medicine, Washington, DC, USA
| | - Rebecca Fisher
- Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - William F Griffin
- Department of Radiology, The George Washington University School of Medicine, Washington, DC, USA
| | - Vishak Kumar
- Department of Cardiology, The George Washington University School of Medicine, Washington, DC, USA
| | - Habib Rahban
- Cardiovascular Research Foundation of Southern California, Beverly Hills, CA, USA
| | - Hugo Marques
- Centro Hospitalar Universitario de Lisboa Central - Servico de Radiologia do Hospital de Santa Marta, Lisboa, Portugal; Nova Medical School - Faculdade de Ciencias Medicas -, Lisboa, Portugal
| | - Ronald P Karlsberg
- Cardiovascular Research Foundation of Southern California, Beverly Hills, CA, USA
| | | | | | - Andrew D Choi
- Department of Cardiology, The George Washington University School of Medicine, Washington, DC, USA; Department of Radiology, The George Washington University School of Medicine, Washington, DC, USA
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Manubolu VS, Roy SK, Budoff MJ. Prognostic Value of Serial Coronary CT Angiography in Atherosclerotic Plaque Modification: What have we learnt? Curr Cardiovasc Imaging Rep 2022; 15:1. [PMID: 35300492 PMCID: PMC8923615 DOI: 10.1007/s12410-022-09564-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of review To provide an update and to outline the status of coronary computer tomography angiography (CCTA) in evaluation of coronary plaques and discuss the relevance of serial CCTA in guiding cardiovascular risk stratification and anti- atherosclerotic medical therapy. Recent Findings Coronary CTA is now the imaging modality of choice in monitoring changes in coronary plaque. It has been used in innumerable clinical trials which have demonstrated the benefits of several therapeutic agents and has excellent correlation with previously used invasive imaging modalities. It is safe, fast, less cumbersome, and a cost-effective testing method compared to other invasive imaging modalities for coronary plaque analysis. Summary The emergence of a noninvasive imaging modality such as CCTA, now permits quantification not only of plaque burden but also allows for further distinction of plaque components and identification of vulnerable plaques. Application of these findings continues to extend the prospect of coronary CTA in evaluation and management of atherosclerotic coronary artery disease (CAD) in clinical practice. In the future artificial intelligence and machine learning will play a significant role in plaque analysis allowing for high accuracy and reproducibility which will lead to a substantial increase in the utilization of coronary CTA.
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Affiliation(s)
| | - Sion K. Roy
- Lundquist Institute, Department of Cardiology, Torrance, CA, USA
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Shaw LJ, Blankstein R, Bax JJ, Ferencik M, Bittencourt MS, Min JK, Berman DS, Leipsic J, Villines TC, Dey D, Al'Aref S, Williams MC, Lin F, Baskaran L, Litt H, Litmanovich D, Cury R, Gianni U, van den Hoogen I, R van Rosendael A, Budoff M, Chang HJ, E Hecht H, Feuchtner G, Ahmadi A, Ghoshajra BB, Newby D, Chandrashekhar YS, Narula J. Society of Cardiovascular Computed Tomography / North American Society of Cardiovascular Imaging - Expert Consensus Document on Coronary CT Imaging of Atherosclerotic Plaque. J Cardiovasc Comput Tomogr 2021; 15:93-109. [PMID: 33303383 DOI: 10.1016/j.jcct.2020.11.002] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Coronary computed tomographic angiography (CCTA) provides a wealth of clinically meaningful information beyond anatomic stenosis alone, including the presence or absence of nonobstructive atherosclerosis and high-risk plaque features as precursors for incident coronary events. There is, however, no uniform agreement on how to identify and quantify these features or their use in evidence-based clinical decision-making. This statement from the Society of Cardiovascular Computed Tomography and North American Society of Cardiovascular Imaging addresses this gap and provides a comprehensive review of the available evidence on imaging of coronary atherosclerosis. In this statement, we provide standardized definitions for high-risk plaque (HRP) features and distill the evidence on the effectiveness of risk stratification into usable practice points. This statement outlines how this information should be communicated to referring physicians and patients by identifying critical elements to include in a structured CCTA report - the presence and severity of atherosclerotic plaque (descriptive statements, CAD-RADS™ categories), the segment involvement score, HRP features (e.g., low attenuation plaque, positive remodeling), and the coronary artery calcium score (when performed). Rigorous documentation of atherosclerosis on CCTA provides a vital opportunity to make recommendations for preventive care and to initiate and guide an effective care strategy for at-risk patients.
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Affiliation(s)
- Leslee J Shaw
- Weill Cornell School of Medicine, New York, NY, USA.
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | - James K Min
- Weill Cornell School of Medicine; Cleerly, Inc. (started in 2020), New York, NY, USA
| | - Daniel S Berman
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Damini Dey
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Fay Lin
- Weill Cornell School of Medicine, New York, NY, USA
| | | | - Harold Litt
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Diana Litmanovich
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ricardo Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami, FL, USA
| | | | | | | | - Matthew Budoff
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | | | | | - Amir Ahmadi
- Mount Sinai School of Medicine, New York, NY, USA
| | | | - David Newby
- University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | | | - Jagat Narula
- Mount Sinai School of Medicine, New York, NY, USA
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Liu T, Wang G, Li P, Dai X. Risk classification of highly sensitive troponin I predict presence of vulnerable plaque assessed by dual source coronary computed tomography angiography. Int J Cardiovasc Imaging 2017; 33:1831-1839. [PMID: 28528430 DOI: 10.1007/s10554-017-1174-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 05/17/2017] [Indexed: 01/10/2023]
Abstract
Patients presenting to the emergency department with acute chest pain, negative conventional troponin and electrocardiogram require serial testing to rule out acute coronary syndrome (ACS). We studied the association of highly sensitive troponin (hsTn) I with vulnerable plaque features as detected by coronary dual source computed tomography angiography (DSCTA) and determined whether hsTn I at the time of presentation combined with early DSCTA could improve classification of patients as high-risk or low risk for ACS. We included 220 patients with acute chest pain, negative electrocardiogram and conventional troponin who underwent DSCTA and had hsTn I measured at the time of presentation. The patients were categorized as having hsTn I below the limit of detection (low risk), intermediate and above the 99th percentile (high risk). Readers assessed DSCTA qualitatively for the presence of significant CAD (≥50% stenosis), calcified and non-calcified coronary plaque, and vulnerable plaque features (positive remodeling, low CT attenuation plaque, napkin-ring sign, spotty calcium). The mean age of the population was 50.3 ± 8.2 years (43% women). ACS during the index hospitalization occurred in 36 (16.3%) patients (myocardial infarction n = 8, unstable angina pectoris n = 28). HsTn I was below the limit of detection, intermediate, and above 99th percentile in 39 (17.7%), 139 (86.9%), and 42 (19.1%) patients, respectively. Across the categories of low risk, intermediate and high risk of hsTn I, there was increase in prevalence of ≥50% stenosis (0, 11.5, and 61.9% of patients; p < 0.001), any plaque (35.9, 51.1, and 85.7% of patients; p < 0.001) and high-risk plaque (0, 36.0, and 85.7% of patients; p < 0.001). None of the patients in low risk HsTn I group had ACS. ACS occurred in 10.1% of the intermediate hsTn I group and in 52.3% of the patients with high risk hsTnI group. Severity of stenosis and presence of vunerable plaque as detected by DSCTA are associated with increasing levels of hsTn I. DSCTA at the time of presentation with the assessment for both stenosis and high-risk plaque improved the diagnostic accuracy for ACS in the intermediate hsTn I group patients.
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Affiliation(s)
- Ting Liu
- Department of Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing Bei St, Heping District, Shenyang, China
| | - Guan Wang
- Department of Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing Bei St, Heping District, Shenyang, China
| | - Peiling Li
- Department of Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing Bei St, Heping District, Shenyang, China
| | - Xu Dai
- Department of Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing Bei St, Heping District, Shenyang, China.
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Thomas DM, Divakaran S, Villines TC, Nasir K, Shah NR, Slim AM, Blankstein R, Cheezum MK. Management of Coronary Artery Calcium and Coronary CTA Findings. Curr Cardiovasc Imaging Rep 2015; 8:18. [PMID: 25960825 PMCID: PMC4412516 DOI: 10.1007/s12410-015-9334-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Coronary artery calcium (CAC) testing and coronary computed tomography angiography (CTA) have significant data supporting their ability to identify coronary artery disease (CAD) and classify patient risk for atherosclerotic cardiovascular disease (ASCVD). Evidence regarding CAC use for screening has established an excellent prognosis in patients with no detectable CAC, and the ability to risk re-classify the majority of asymptomatic patients considered intermediate risk by traditional risk scores. While data regarding the ideal management of CAC findings are limited, evidence supports statin consideration in patients with CAC > 0 and individualized aspirin therapy accounting for CAD risk factors, CAC severity, and factors which increase a patient’s risk of bleeding. In patients with stable or acute symptoms undergoing coronary CTA, a normal CTA predicts excellent prognosis, allowing reassurance and disposition without further testing. When CTA identifies nonobstructive CAD (<50 % stenosis), observational data support consideration of statin use/intensification in patients with extensive plaque (at least four coronary segments involved) and patients with high-risk plaque features. In patients with both nonobstructive and obstructive CAD, multiple studies have now demonstrated an ability of CTA to guide management and improve CAD risk factor control. Still, significant under-treatment of cardiovascular risk factors and high-risk image findings remain, among concerns that CTA may increase invasive angiography and revascularization. To fully realize the impact of atherosclerosis imaging for ASCVD prevention, patient engagement in lifestyle changes and the modification of ASCVD risk factors remain the foundation of care. This review provides an overview of available data and recommendations in the management of CAC and CTA findings.
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Affiliation(s)
- Dustin M Thomas
- Department of Medicine (Cardiology Service), San Antonio Military Medical Center, San Antonio, TX USA
| | - Sanjay Divakaran
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA USA
| | - Todd C Villines
- Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Khurram Nasir
- Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL USA
| | - Nishant R Shah
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, MA USA
| | - Ahmad M Slim
- Department of Medicine (Cardiology Service), San Antonio Military Medical Center, San Antonio, TX USA
| | - Ron Blankstein
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, MA USA
| | - Michael K Cheezum
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, MA USA ; Non-invasive Cardiovascular Imaging Program, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 USA
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Affiliation(s)
- A B Mehta
- Director of Cardiology, Jaslok Hospital and Research Centre, Mumbai
| | - Sameer Shah
- Registrar, Jaslok Hospital and Research Centre, Mumbai
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