Prognostic value of segment involvement score compared to other measures of coronary atherosclerosis by computed tomography: A systematic review and meta-analysis

Latent Tuberculosis Infection and Subclinical Coronary Atherosclerosis in Peru and Uganda

BACKGROUND

Tuberculosis has been linked to an increased risk of atherosclerotic cardiovascular disease (ASCVD). We assessed whether latent tuberculosis infection (LTBI) is associated with subclinical coronary atherosclerosis in two TB-prevalent areas.

METHODS

We analyzed cross-sectional data from studies conducted in Lima, Peru, and Kampala, Uganda. Individuals ≥40 years old were included. We excluded persons with known history of ASCVD events or active TB. Participants underwent QuantiFERON®-TB (QFT) testing to define LTBI, and computed tomography angiography to examine coronary atherosclerosis. A Coronary Artery Disease-Reporting Data System (CAD-RADS) score ≥3 defined obstructive CAD (plaque causing ≥50% stenosis).

RESULTS

113 persons with LTBI and 91 persons without LTBI were included. There were no significant differences between LTBI and non-LTBI participants in terms of age (median [interquartile range]; 56 [51-62] vs. 55 [49-64], p=0.829), male sex (38% vs. 42%; p=0.519), or 10-year ASCVD risk scores (7.1 [3.2-11.7] vs. 6.1 [2.8-10.8]; p=0.533). CAD prevalence (any plaque) was similar between groups (29% vs. 24%; p=0.421). Obstructive CAD was present in 9% of LTBI and 3% of non-LTBI individuals; p=0.095. LTBI was associated with obstructive CAD after adjusting for ASCVD risk score, HIV status, and study site (adjusted odds ratio, 4.96, 95% CI 1.05-23.44; p=0.043). Quantitative QFT TB antigen minus nil interferon-gamma responses were associated with obstructive CAD (adjusted odds ratio, 1.2, 95% CI 1.03-1.41; p=0.022).

CONCLUSIONS

LTBI was independently associated with an increased likelihood of subclinical obstructive CAD. Our data indicates that LTBI is a non-traditional correlate of ASCVD risk.

Prevalence of coronary atherosclerosis and reclassification of cardiovascular risk in Spanish population by coronary computed tomography angiography: EVA study

BACKGROUND

A more complete assessment of coronary artery disease (CAD) can be performed by coronary computed tomography angiography (CCTA). The aim was to assess the prevalence, distribution and characteristics of coronary artery disease (CAD) and the reclassification of cardiovascular risk by CCTA in an asymptomatic Spanish population.

DESIGN

We included, in a cross-sectional study, 501 random subjects from asymptomatic population, aged 35 and 75. Risk factors, target organ damage and cardiovascular risk were assessed. CCTA was offered to measure the coronary artery calcium score(CACS), segment involvement score(SIS) and segment stenosis score(SSS). The offer was accepted by 220 subjects (44%), with a mean age of 58 ± 14 years, 56% of them male.

RESULTS

The mean CACS was 119.6 ± 381.7 (median (IQR) (0 (0-61.55))), with higher scores in males (191.9 ± 493.1) than females (26.1 ± 73.3; P < .01). CCTA revealed coronary atherosclerosis in 89 cases, 40% (CI95%:34%-46%) in global, 51% in male and 25% in female, of which 13 had obstructive lesions (5.9%). Mean SIS was 1.5 ± 2.5 and SSS 1.2 ± 3.1. When the CACS was included in the CAD risk scale, there was a reclassification of 24%, and when using the SIS percentile, it was 38%, with a 9% increase in risk in both cases.

CONCLUSIONS

The prevalence of CAD in asymptomatic Spanish population was 40%, with greater proportion among males. The incorporation of CACS and SIS in the assessment of cardiovascular risk allows reclassifying subjects who are at low or moderate risk and thus identify those with high cardiovascular risk and also the other way.

Exercise and Coronary Atherosclerosis: Observations, Explanations, Relevance, and Clinical Management

Physical activity and exercise training are effective strategies for reducing the risk of cardiovascular events, but multiple studies have reported an increased prevalence of coronary atherosclerosis, usually measured as coronary artery calcification, among athletes who are middle-aged and older. Our review of the medical literature demonstrates that the prevalence of coronary artery calcification and atherosclerotic plaques, which are strong predictors for future cardiovascular morbidity and mortality, was higher in athletes compared with controls, and was higher in the most active athletes compared with less active athletes. However, analysis of plaque morphology revealed fewer mixed plaques and more often only calcified plaques among athletes, suggesting a more benign composition of atherosclerotic plaques. This review describes the effects of physical activity and exercise training on coronary atherosclerosis in athletes who are middle-aged and older and aims to contribute to the understanding of the potential adverse effects of the highest doses of exercise training on the coronary arteries. For this purpose, we will review the association between exercise and coronary atherosclerosis measured using computed tomography, discuss the potential underlying mechanisms for exercise-induced coronary atherosclerosis, determine the clinical relevance of coronary atherosclerosis in middle-aged athletes and describe strategies for the clinical management of athletes with coronary atherosclerosis to guide physicians in clinical decision making and treatment of athletes with elevated coronary artery calcification scores.

Latest Advances in Cardiac CT

Recent rapid technological advancements in cardiac CT have improved image quality and reduced radiation exposure to patients. Furthermore, key insights from large cohort trials have helped delineate cardiovascular disease risk as a function of overall coronary plaque burden and the morphological appearance of individual plaques. The advent of CT-derived fractional flow reserve promises to establish an anatomical and functional test within one modality. Recent data examining the short-term impact of CT-derived fractional flow reserve on downstream care and clinical outcomes have been published. In addition, machine learning is a concept that is being increasingly applied to diagnostic medicine. Over the coming decade, machine learning will begin to be integrated into cardiac CT, and will potentially make a tangible difference to how this modality evolves. The authors have performed an extensive literature review and comprehensive analysis of the recent advances in cardiac CT. They review how recent advances currently impact on clinical care and potential future directions for this imaging modality.

Long-term prognostic utility of computed tomography coronary angiography in older populations

Aims

The long-term prognostic value of coronary computed tomography angiography (CCTA)-identified coronary artery disease (CAD) has not been evaluated in elderly patients (≥70 years). We compared the ability of coronary CCTA to predict 5-year mortality in older vs. younger populations.

Methods and results

From the prospective CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry, we analysed CCTA results according to age <70 years (n = 7198) vs. ≥70 years (n = 1786). The severity of CAD was classified according to: (i) maximal stenosis degree per vessel: none, non-obstructive (1–49%), or obstructive (>50%); (ii) segment involvement score (SIS): number of segments with plaque. Cox-proportional hazard models assessed the relationship between CCTA findings and time to mortality. At a mean 5.6 ± 1.1 year follow-up, CCTA-identified CAD predicted increased mortality compared with patients with a normal CCTA in both <70 years [non-obstructive hazard ratio (HR) confidence interval (CI): 1.70 (1.19–2.41); one-vessel: 1.65 (1.03–2.67); two-vessel: 2.24 (1.21–4.15); three-vessel/left main: 4.12 (2.27–7.46), P < 0.001] and ≥70 years [non-obstructive: 1.84 (1.15–2.95); one-vessel: HR (CI): 2.28 (1.37–3.81); two-vessel: 2.36 (1.33–4.19); three-vessel/left main: 2.41 (1.33–4.36), P = 0.014]. Similarly, SIS was predictive of mortality in both <70 years [SIS 1–3: 1.57 (1.10–2.24); SIS ≥4: 2.42 (1.65–3.57), P < 0.001] and ≥70 years [SIS 1–3: 1.73 (1.07–2.79); SIS ≥4: 2.45 (1.52–3.93), P < 0.001]. CCTA findings similarly predicted long-term major adverse cardiovascular outcomes (MACE) (all-cause mortality, myocardial infarction, and late revascularization) in both groups compared with patients with no CAD.

Conclusion

The presence and extent of CAD is a meaningful stratifier of long-term mortality and MACE in patients aged <70 years and ≥70 years old. The presence of obstructive and non-obstructive disease and the burden of atherosclerosis determined by SIS remain important predictors of prognosis in older populations.

Comprehensive coronary plaque assessment in patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) is associated with an increased risk of cardiovascular disease. Previous studies have assessed the relationship between OSA and coronary artery disease (CAD) using coronary artery calcium score (CAC) measurements. However, limited data are available regarding the association of OSA with non-calcified plaque burden. We therefore aimed to assess the relationship between CAD severity as assessed by coronary computed tomography angiography (CTA) and OSA. Forty-one adult subjects (59 ± 9 years, 15 men) underwent a 256-slice coronary CTA, which was followed by a diagnostic attended cardiorespiratory polygraphy (n = 13) or polysomnography (n = 28). Segment involvement score (SIS), segment stenosis score (SSS) and CAC were used to quantify total CAD burden. Correlation analysis was used to assess potential associations between CAD and OSA. Twenty-two patients were diagnosed with OSA. SIS and SSS were elevated in OSA (2.90 ± 2.78 versus 1.79 ± 2.39 and 4.91 ± 5.94 versus 1.79 ± 4.54, OSA versus controls, SIS and SSS respectively, both p < 0.01) and correlated with OSA severity as measured by the apnea-hypopnea index (AHI, r = 0.41 and 0.43, p < 0.01) and oxygen desaturation index (ODI, r = 0.45 and 0.46, p < 0.01). However, no significant correlation was observed between CAC and OSA. Compared to CAC, SIS and SSS provide additional information on coronary plaque burden in OSA, which shows a significant association with OSA.

Coronary computed tomography angiography detection of short- and long-term outcomes after heart valve surgery with high risk cardiovascular patients

Coronary computed tomography angiography (CCTA) is a promising alternative technique to detect significant coronary artery lesions in high-risk cardiovascular patients with left ventricular dysfunction (left ventricular ejection fractions < 40%) referred for elective valve surgery, while little research about the use of CCTA to detect the outcomes of heart valve surgery was performed. Forty-six consecutive high-risk cardiovascular patients with the New York Heart Association (NYHA) classification were retrospectively studied. Immediate, 10-week, 20-week, and 40-week outcomes after heart valve surgery were assessed with CCTA. Patients' average age at the time of surgery was 73 years, with the majority being male (54.35%). Among the CCTA parameters detected after 10, 20, and 40 weeks after heart valve surgery, only segment involvement score (SIS) did reach statistical significance when compared with baseline levels. The cumulative mortality rate at 10, 20, and 40 weeks were 19.56%, 30.43%, and 39.13% respectively. It can be seen that the early death is mainly due to complications, and with the time-lapse of surgery, the impact of complications on death is gradually eliminated. CCTA might be a useful tool to detect the outcomes of short- and long-term outcomes after heart valve surgery with high risk cardiovascular patients, and SIS level is associated with the short- and long-term outcomes.

Long-Term Prognostic Value of Coronary Computed Tomography Angiography

OPINION STATEMENT

Coronary CT angiography (CTA) is a highly accurate test for the diagnosis of coronary artery disease (CAD), with its use guided by numerous contemporary appropriate use criteria and clinical guidelines. Unique among non-invasive tests for CAD, coronary CTA provides direct visualization of coronary atherosclerosis for the assessment of angiographic stenosis, as well as validated measures of plaque vulnerability. Long-term studies now clearly demonstrate that the absence of CAD on coronary CTA identifies a patient that is at very low risk for future cardiovascular events. Conversely, the presence, location, and severity of CAD as measured on coronary CTA provide powerful prognostic information that is superior to traditional risk factors and other clinical variables. Observational studies and data obtained from clinical trials suggest that the anatomic information derived from coronary CTA significantly increases the utilization of statins and aspirin. Furthermore, these changes are associated with reductions in the risk for mortality, revascularizations, and incident myocardial infarctions among subjects with coronary atherosclerosis. As a result, current societal consensus statements have attempted to standardize coronary CTA reporting, to include incorporation of vulnerable plaque features and recommendations on the use of preventive therapies, such as statins, so to more consistently link important prognostic findings on coronary CTA to appropriate preventive and therapeutic interventions. Automated measures of total coronary plaque volume, machine learning, and CT-derived fractional flow reserve may further refine the prognostic accuracy of coronary CTA. Herein, we summarize recently published literature that reports the long-term (≥ 5 years of follow-up) prognostic usefulness of coronary CTA.