Role of Coronary Artery Calcium Score and Coronary CT Angiography in the Diagnosis and Risk Stratification of Individuals with Suspected Coronary Artery Disease

ACR Appropriateness Criteria® Asymptomatic Patient at Risk for Coronary Artery Disease: 2021 Update

Coronary atherosclerotic disease is a leading cause of mortality and morbidity due to major cardiovascular events in the United States and abroad. Risk stratification and early preventive measures can reduce major cardiovascular events given the long latent asymptomatic period. Imaging tests can detect subclinical coronary atherosclerosis and aid initiation of targeted preventative efforts based on patient risk. A summary of available imaging tests for low-, intermediate-, and high-risk asymptomatic patients is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

18F-FDG uptake velocity but not uptake level is associated with progression of carotid plaque

OBJECTIVES

The objective of this study was to evaluate whether baseline ¹⁸F-fluorodeoxyglucose (FDG) uptake is associated with carotid plaque progression.

METHODS

A total of 156 subjects with carotid plaque were enrolled and underwent carotid magnetic resonance imaging (MRI) (at baseline and the 12-month follow-up) and positron emission tomography-computed tomography (PET-CT) (baseline). Carotid plaque progression was evaluated by two indices (the incidence of plaque progression and percentage of plaque increase) with three-dimensional (3D) imaging, while the ¹⁸F-FDG uptake was evaluated by the ¹⁸F-FDG uptake levels and ¹⁸F-FDG uptake velocity. The association between plaque progression and ¹⁸F-FDG uptake was investigated by the trend test and multivariate logistic regression analysis.

RESULTS

Of the 156 subjects, 80 (51.3%) showed carotid plaque progression during the 12-month follow-up. Firstly, no association was found between ¹⁸F-FDG uptake levels and plaque progression. Secondly, significant differences in the incidence of plaque progression were observed among the groups with different uptake velocities, showing a significant decreasing trend ranging from high to intermediate to low (p = 0.002, trend test). After adjusting for covariates, an adequate prediction of the ¹⁸F-FDG uptake velocity for the incidence of plaque progression was revealed (OR = 0.682, p < 0.05). In addition, no association was found between the ¹⁸F-FDG uptake velocity and the percentage of plaque increase in the subjects with plaque progression (p = 0.757, trend test).

CONCLUSIONS

Our findings suggest ¹⁸F-FDG uptake velocity is independently associated with the incidence of carotid plaque progression. Additionally, the ¹⁸F-FDG uptake velocity, as another important parameter of PET-CT, warrants further study in future clinical research.

KEY POINTS

• The¹⁸F-FDG uptake levels were not associated with the carotid plaque progression. • The¹⁸F-FDG uptake velocity could predict the incidence of carotid plaque progression. • The¹⁸F-FDG uptake velocity with related factors warrants more attention in future clinical research.

Development and Validation of a Simple-to-Use Nomogram for Predicting 5-, 10-, and 15-Year Survival in Asymptomatic Adults Undergoing Coronary Artery Calcium Scoring

OBJECTIVES

The purpose of this study was to develop and validate a simple-to-use nomogram for prediction of 5-, 10-, and 15-year survival among asymptomatic adults.

BACKGROUND

Simple-to-use prognostication tools that incorporate robust methods such as coronary artery calcium scoring (CACS) for predicting near-, intermediate- and long-term mortality are warranted.

METHODS

In a consecutive series of 9,715 persons (mean age: 53.4 ± 10.5 years; 59.3% male) undergoing CACS, we developed a nomogram using Cox proportional hazards regression modeling that included: age, sex, smoking, hypertension, dyslipidemia, diabetes, family history of coronary artery disease, and CACS. We developed a prognostic index (PI) summing the number of risk points corresponding to weighted covariates, which was used to configure the nomogram. Validation of the nomogram was assessed by discrimination and calibration applied to a separate cohort of 7,824 adults who also underwent CACS.

RESULTS

A total of 936 and 294 deaths occurred in the derivation and validation sets at a median follow-up of 14.6 years (interquartile range: 13.7 to 15.5 years) and 9.4 years (interquartile range: 6.8 to 11.5 years), respectively. The developed model effectively predicted 5-, 10-, and 15-year probability of survival. The PI displayed high discrimination in the derivation and validation sets (C-index 0.74 and 0.76, respectively), indicating suitable external performance of our nomogram model. The predicted and actual estimates of survival in each dataset according to PI quartiles were similar (though not identical), demonstrating improved model calibration.

CONCLUSIONS

A simple-to-use nomogram effectively predicts 5-, 10- and 15-year survival for asymptomatic adults undergoing screening for cardiac risk factors. This nomogram may be considered for use in clinical care.

Progression of noncalcified and calcified coronary plaque by CT angiography in SLE

Premature coronary artery disease remains the major cause of late death in systemic lupus erythematosus (SLE). Coronary artery calcium (CAC) represents an advanced stage of atherosclerosis, whereas noncalcified coronary atherosclerotic plaque (NCP) typically is more prone to trigger acute coronary events. The aim of this study was to assess the stability of NCP over time and identify factors associated with changes in NCP in patients with SLE. CT coronary angiography and calcium scanning were performed at baseline and follow-up in thirty-six SLE patients. Duration between baseline and follow-up NCP assessment ranged from 2 to 8 years. CAC was quantified by the Agatston score and classified as none, low (1-99), moderate (100-299) or high calcium score (300 and above). NCP was quantified based on a previously validated score and classified as none, low (<0.5) or high (0.5+). SLE disease activity was quantified using the SELENA-SLEDAI and physician global assessment indices. To assess the association between quantitative clinical variables and changes in NCP, adjusting for time, we used linear regression models. The group of 36 SLE patients were 75% females, 75% Caucasians, 17% African-Americans, 8% other ethnicities. The mean age of patients was 46.6 years. For NCP, 17/36 (47%) of the patients switched qualitative NCP class (none, low, high) between baseline and follow-up, whereas for CAC only 3/35 (9%) switched qualitative class. Increasing years between assessments were associated with an increase in NCP (P = 0.038). The proportion of time on immunosuppressants was associated with a decrease in NCP (P = 0.06). Calcified coronary plaque levels remained relatively stable over a period of 2-8 years. Noncalcified coronary plaque levels were more variable. Use of immunosuppressive drugs appeared to be protective against noncalcified coronary plaque progression.

Comorbidities impacting on prognosis after lung transplant

The aim of this review is to give an overview of the clinical circumstances presenting before lung transplant that may have negative repercussions on the long and short-term prognosis of the transplant. Methods for screening and diagnosis of common comorbidities with negative impact on the prognosis of the transplant are proposed, both for pulmonary and extrapulmonary diseases, and measures aimed at correcting these factors are discussed. Coordination and information exchange between referral centers and transplant centers would allow these comorbidities to be detected and corrected, with the aim of minimizing the risks and improving the life expectancy of transplant receivers.