Meta-Analysis and Systematic Review of the Long-Term Predictive Value of Assessment of Coronary Atherosclerosis by Contrast-Enhanced Coronary Computed Tomography Angiography

Exercise-induced cardiac troponin release in athletes with versus without coronary atherosclerosis

The magnitude of exercise-induced cardiac troponin (cTn) elevations is dependent on cardiovascular health status, and previous studies have shown that occult coronary atherosclerosis is highly prevalent among amateur athletes. We tested the hypothesis that middle-aged and older athletes with coronary atherosclerosis demonstrate greater cTn elevations following a controlled endurance exercise test compared with healthy peers. We included 59 male athletes from the Measuring Athletes' Risk of Cardiovascular events 2 (MARC-2) study and stratified them as controls [coronary artery calcium score (CACS) = 0, n = 20], high CACS [≥300 Agatston units or ≥75th Multi-Ethnic Study of Atherosclerosis (MESA) percentile, n = 20] or significant stenosis (≥50% in any coronary artery, n = 19). Participants performed a cycling test with incremental workload until volitional exhaustion. Serial high-sensitivity cTn (hs-cTn) T and I concentrations were measured (baseline, after 30-min warm-up, and 0, 30, 60, 120, and 180 min postexercise). There were 58 participants (61 [58-69] yr) who completed the exercise test (76 ± 14 min) with a peak heart rate of 97.7 [94.8-101.8]% of their estimated maximum. Exercise duration and workload did not differ across groups. High-sensitivity cardiac troponin T (Hs-cTnT) and high-sensitivity cardiac troponin I (hs-cTnI) concentrations significantly increased (1.55 [1.33-2.14]-fold and 2.76 [1.89-3.86]-fold, respectively) over time, but patterns of cTn changes and the incidence of concentrations >99th percentile did not differ across groups. Serial sampling of hs-cTnT and hs-cTnI concentrations during and following an exhaustive endurance exercise test did not reveal differences in exercise-induced cTn release between athletes with versus without coronary atherosclerosis. These findings suggest that a high CACS or a >50% stenosis in any coronary artery does not aggravate exercise-induced cTn release in middle-aged and older athletes.NEW & NOTEWORTHY Exercise-induced cardiac troponin (cTn) release is considered to be dependent on cardiovascular health status. We tested whether athletes with coronary atherosclerosis demonstrate greater exercise-induced cTn release compared with healthy peers. Athletes with coronary atherosclerosis did not differ in cTn release following exercise compared with healthy peers. Our findings suggest that a high CACS or a >50% stenosis in any coronary artery does not aggravate exercise-induced cTn release in middle-aged and older athletes.

Coronary Plaque in Athletes

The relationship between vigorous physical activity (PA) and the development of coronary atherosclerosis has remained less explored for many years. Recently, literature data have focused on coronary atherosclerosis in athletes showing that prevalence is not trivial, that there are differences among various types of sport, and that there are some peculiar features. As a matter of fact, plaque composition in athletes seems to be characterized by calcium rather than soft components. Specific mechanisms through which vigorous PA influences coronary artery disease are not yet fully understood. However, the prevalent calcific nature of coronary plaques in athletes could be related with a trend in a lower cardiovascular event rate.

Non-Contrast and Contrast-Enhanced Cardiac Computed Tomography Imaging in the Diagnostic and Prognostic Evaluation of Coronary Artery Disease

In recent decades, cardiac computed tomography (CT) has emerged as a powerful non-invasive tool for risk stratification, as well as the detection and characterization of coronary artery disease (CAD), which remains the main cause of morbidity and mortality in the world. Advances in technology have favored the increasing use of cardiac CT by allowing better performance with lower radiation doses. Coronary artery calcium, as assessed by non-contrast CT, is considered to be the best marker of subclinical atherosclerosis, and its use is recommended for the refinement of risk assessment in low-to-intermediate risk individuals. In addition, coronary CT angiography (CCTA) has become a gate-keeper to invasive coronary angiography (ICA) and revascularization in patients with acute chest pain by allowing the assessment not only of the extent of lumen stenosis, but also of its hemodynamic significance if combined with the measurement of fractional flow reserve or perfusion imaging. Moreover, CCTA provides a unique incremental value over functional testing and ICA by imaging the vessel wall, thus allowing the assessment of plaque burden, composition, and instability features, in addition to perivascular adipose tissue attenuation, which is a marker of vascular inflammation. There exists the potential to identify the non-obstructive lesions at high risk of progression to plaque rupture by combining all of these measures.

High-risk Coronary Plaque Regression in Cash-based Contingency Management Intervention Among Cocaine Users With HIV-associated Subclinical Coronary Atherosclerosis

BACKGROUND

Cocaine use exacerbates human immunodeficiency virus (HIV)-associated subclinical coronary atherosclerosis. We investigated whether cocaine abstinence or reduced use achieved with contingency management (CM) intervention would retard high-risk coronary plaque progression among cocaine users with HIV and subclinical coronary atherosclerosis.

METHODS

Between March 2014 and August 2017, 76 cocaine users with HIV and coronary plaques were enrolled in a study designed to decrease cocaine use and determine whether doing so impacted progression of subclinical coronary atherosclerosis as measured by coronary artery computed tomography examinations. Of the 76, 7 did not complete the study, resulting in 69 participants. A 12-month cash-based CM intervention was implemented to promote cocaine abstinence or reduced cocaine use. Generalized estimating equation approach was used to perform longitudinal data analyses.

FINDINGS

During the 12-month CM, all 69 participants reduced cocaine use, and of these, 25 (36%; 95% confidence interval, 25%-49%) achieved cocaine abstinence. After adjusting for potential confounding factors, generalized estimating equation analyses showed that (1) endothelin-1 (ET-1) levels, a proinflammatory biomarker for endothelial dysfunction, at the 6-month and 12-month visits were significantly lower compared with baseline ET-1 ( P = 0.001 and P < 0.001, respectively), and (2) low-attenuation noncalcified coronary plaque volume, a predictor for myocardial infarction, at 12-month visit was significantly lower compared with baseline low-attenuation noncalcified coronary plaque volume ( P < 0.05).

CONCLUSIONS

The findings of this study have not only demonstrated that CM is effective in achieving a sustained reduction in cocaine use, but also provided compelling evidence that reduction in cocaine use leads to quantifiable cardiovascular health benefits, including concurrent decrease in high-risk plaque burden and ET-1, among cocaine users with HIV-associated coronary atherosclerosis.

Myocardial Fibrosis and Coronary Calcifications Caused by Endurance Exercise? Insights from Former Professional Cyclists

PURPOSE

This study aimed to compare the prevalence of myocardial fibrosis and coronary calcification in individuals who have performed very high levels of strenuous endurance exercise (SEE; former male professional cyclists) and sex/age-matched controls.

METHODS

We used a retrospective cohort study design, where cases were former finishers of ≥1 Grand Tour (Tour de France, Giro d' Italia or Vuelta a España) and controls were untrained individuals free of cardiovascular risk. All participants underwent cardiac magnetic resonance and cardiac computer tomography in the same center during years 2020-2021 to detect myocardial fibrosis (late gadolinium enhancement) and to quantify coronary calcium, respectively.

RESULTS

Twenty-three cases (age, 46 ± 6 yr) and 59 controls (47 ± 7 yr) were studied. Fibrotic patches were evidenced only in the left ventricle, with a higher prevalence in cases (23% vs 2% in controls, P = 0.006). However, fibrotic tissue was nonischemic and of low extension (0.6% ± 0.4% of left ventricle mass), and no significant differences were found between cases and controls for native T1 or T2 values. No between-group differences were found for coronary calcium indicators, including Agatston or density scores. Subanalyses revealed no differences attending to whether cases were still performing regular SEE ( n = 8) or not ( n = 15) after professional retirement.

CONCLUSIONS

Although former professional cyclists seemed to show a greater prevalence of myocardial fibrosis, the extension of fibrotic tissue was minimal and no alterations were found in coronary calcification indicators. While keeping in mind the low sample size of the cases' group, our results do not support evidence for major cardiac maladaptations with long-term exposure to SEE, at least in middle-age adults.

Coronary bioresorbable stents: Non-invasive quantitative evaluation of intra- and juxta-stent plaque composition-A computed tomography longitudinal study

PURPOSE

Coronary bioresorbable stents (BRS) do not produce blooming artifacts on computed tomography (CT), in contrast to metallic stents, as they are made of a bioresorbable polymer and are radiolucent. They allow to evaluate the coronary plaque beneath. The low-attenuation plaque (LAP) suggests plaque vulnerability and is CT assessable. The aim of our study was to show the possibility of a non-invasive CT evaluation of the volume and the LAP composition of the intra- and juxta-stent plaque.

METHODOLOGY

In our prospective longitudinal study, we recruited 27 consecutive patients (35 BRS stents total; mean age 60 +/- 9 years) with bioresorbable stents for a 256-slice ECG-synchronized CT evaluation at 1- and 12-months post stent implantation. Total plaque volume (mm3), absolute and relative (%) LAP volume per block in the pre- intra- and post-stent zones were analyzed; comparison 1- and 12-months post-implantation of BRS. Changes in the previously mentioned variables were assessed by the mixed effects models with and without spline, which also accounted for the correlation between repeated measurements.

RESULTS

Our block or spline model analysis has shown no significant difference in plaque or absolute LAP volumes in pre- intra- and post-stent zones between 1 and 12 months. Interestingly, % LAP volume increases near-significantly in the distal block of the intrastent at 12-mo follow-up (from 23.38 ± 1.80% to 26.90 ± 2.22% (increase of 15%), p = 0.052).

CONCLUSION

Our study demonstrates the feasibility of the repeated non-invasive quantitative analysis of the intrastent coronary plaque and of the in-stent lumen by CT scan.

Strenuous Endurance Exercise and the Heart: Physiological versus Pathological Adaptations

Although the benefits of regular physical activity on cardiovascular health are well established, the effects of strenuous endurance exercise (SEE) have been a matter of debate since ancient times. In this article, we aim to provide a balanced overview of what is known about SEE and the heart-from epidemiological evidence to recent cardiac imaging findings. Lifelong SEE is overall cardioprotective, with endurance master athletes showing in fact a youthful heart. Yet, some lines of research remain open, such as the need to elucidate the time-course and potential relevance of transient declines in heart function (or increases in biomarkers of cardiac injury) with SEE. The underlying mechanisms and clinical relevance of SEE-associated atrial fibrillation, myocardial fibrosis, or high coronary artery calcium scores also remain to be elucidated. © 2022 American Physiological Society. Compr Physiol 12:1-19, 2022.

Hormone therapy and cardiovascular disease: Benefits and harms

Menopause transition marks an important phase in life when cardiovascular risk in women gradually takes an adverse turn. Although menopausal hormone therapy has gained a negative appreciation over the last decades, its value in the treatment of disabling vasomotor symptoms is still undisputed. Cardiovascular risk assessment has become a matter of precision medicine, which is helpful for safe menopausal hormone therapy prescription. With a multidisciplinary approach the current available hormone regimens can be even given to women at intermediate cardiovascular risk, when risk factors such as hypertension and dyslipidemia are adequately monitored and treated.

Cardiovascular Evaluation of Liver Transplant Patients by Using Coronary Calcium Scoring in ECG-Synchronized Computed Tomographic Scans

Background: The goal of cardiac evaluation of patients awaiting orthotopic liver transplantation (OLT) is to identify the patients at risk for cardiovascular events (CVEs) in the peri- and postoperative periods by opportunistic evaluation of coronary artery calcium (CAC) in non-gated abdominal computed tomographs (CT). Methods: We hypothesized that in patients with OLT, a combination of Lee’s revised cardiac index (RCRI) and CAC scoring would improve diagnostic accuracy and prognostic impact compared to non-invasive cardiac testing. Therefore, we retrospectively evaluated 169 patients and compared prediction of CVEs by both methods. Results: Standard workup identified 22 patients with a high risk for CVEs during the transplant period, leading to coronary interventions. Eighteen patients had a CVE after transplant and a CAC score > 0. The combination of CAC and RCRI ≥ 2 had better negative (NPV) and positive predictive values (PPV) for CVEs (NPV 95.7%, PPV 81.6%) than standard non-invasive stress tests (NPV 92.0%, PPV 54.5%). Conclusion: The cutoff value of CAC > 0 by non-gated CTs combined with RCRI ≥ 2 is highly sensitive for identifying patients at risk for CVEs in the OLT population.

The relationship between coronary stent strut thickness and the incidences of clinical outcomes after drug-eluting stent implantation: A systematic review and meta-regression analysis

BACKGROUND

Drug-eluting stents (DESs) have been developed with thinner stent struts, and more biocompatible polymers and anti-proliferative drugs to improve the clinical performance. However, it remains unclear whether thinner struts are associated with favorable short- and long-term clinical outcomes such as target lesion revascularization (TLR), periprocedural myocardial infarction (PMI), and stent thrombosis (ST).

METHODS

We searched MEDLINE, Embase and other online sources for randomized controlled trials (RCTs) comparing clinical outcomes between a DES and other stent(s), with independent clinical event adjudication. We investigated stent-related events (TLR, PMI, and ST) in 5 years. Each outcome was analyzed with random-effects meta-regression model against strut thickness, then adjusted for DES generation and patient and lesion characteristics.

RESULTS

We identified 49 RCTs enrolling 97,465 patients, of which strut thickness ranged from 60 to 140 μm. Incidences of 1-year TLR, PMI, and early ST were reduced with thinner stent struts, when adjusted for stent generation (adjusted relative risk [RR] per 10 μm increase 1.12 [95% CI 1.04-1.21], 1.15 [95% CI 1.05-1.26], and 1.15 [95% CI 1.06-1.25], respectively). Strut thickness was not independently associated with incidences of 5-year TLR, late and very late ST. In addition, early DESs contributed to a higher incidence of very late ST (adjusted RR 2.97 [95% CI 1.36-6.50]).

CONCLUSIONS

In this meta-regression analysis, a thinner strut thickness was associated with reduced incidences of early stent-related adverse events (1-year TLR, PMI, and early ST), but not with later events (5-year TLR, late ST, and very late ST).

The heart of the ageing endurance athlete: the role of chronic coronary stress

Moderate physical exercise is associated with an irrefutable reduction in cardiac morbidity and mortality. The current guidelines recommend at least 150 min of moderate exercise or 75 min of vigorous exercise per week. Endurance athletes perform exercise at a level that is 10- to 20-fold greater than these recommendations. These athletes reveal several structural and functional cardiac adaptations including increased cardiac size, enhanced ventricular filling, and augmentation of stroke volume even at the highest heart rates. The long-term effects of endurance exercise on the heart are unknown. Endurance exercise is associated with a transient increase in serum concentrations of biomarkers of cardiac damage and ventricular dysfunction which improves within 72 h. Over the past decade, there have been emerging studies reporting attenuated mortality benefit amongst individuals who perform the highest volume of exercise. Studies in lifelong male athletes aged above 40 years old show a higher prevalence of high coronary artery calcium scores (>300 Agatston units), a higher coronary plaque burden, and myocardial fibrosis compatible with subclinical myocardial infarction compared with relatively sedentary healthy controls, raising speculation that lifelong intense exercise imposes chronic coronary stress on the heart. This review article will provide a critical analysis of the existing data.

Increased Circulating Malondialdehyde-Modified Low-Density Lipoprotein Level Is Associated with High-Risk Plaque in Coronary Computed Tomography Angiography in Patients Receiving Statin Therapy

Objective: To evaluate the association of serum malondialdehyde low-density lipoprotein (MDA-LDL), an oxidatively modified LDL, with the prevalence of high-risk plaques (HRP) determined with coronary computed tomography angiography (CTA) in statin-treated patients. Methods: This study was a single-center retrospective cohort comprising 268 patients (mean age 67 years, 58% men) with statin therapy and who underwent coronary CTA for suspected stable coronary artery disease. Patients were classified into two groups according to median MDA-LDL level or median LDL-C level. Coronary CTA-verified HRP was defined when two or more characteristics, including positive remodeling, low-density plaques, and spotty calcification, were present. Results: Patients with HRP had higher MDA-LDL (p = 0.011), but not LDL-C (p = 0.867) than those without HRP. High MDA-LDL was independently associated with HRP (odds ratio 1.883, 95% confidential interval 1.082–3.279) after adjustment for traditional risk factors. Regarding incremental value of MDA-LDL for predicting CTA-verified HRP, addition of serum MDA-LDL levels to the baseline model significantly increased global chi-square score from 26.1 to 32.8 (p = 0.010). Conclusions: A high serum MDA-LDL level is an independent predictor of CTA-verified HRP, which can lead to cardiovascular events in statin-treated patients.

Society of Cardiovascular Computed Tomography / North American Society of Cardiovascular Imaging - Expert Consensus Document on Coronary CT Imaging of Atherosclerotic Plaque

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.

Retinal Microvascular Signs as Screening and Prognostic Factors for Cardiac Disease: A Systematic Review of Current Evidence

The substantial burden of heart disease promotes an interest in new ways of screening for early disease diagnosis, especially by means of noninvasive imaging. Increasing evidence for association between retinal microvascular signs and heart disease prompted us to systematically investigate the relevant current literature on the subject. We scrutinized the current literature by searching PubMed and Embase databases from 2000 to 2020 for clinical studies of the association between retinal microvascular signs and prevalent or incident heart disease in humans. Following exclusions, we extracted the relevant data from 42 publications (comprising 14 prospective, 26 cross-sectional, and 2 retrospective studies). Our search yielded significant associations between retinal vascular changes, including diameter, tortuosity, and branching, and various cardiac diseases, including acute coronary syndrome, coronary artery disease, heart failure, and conduction abnormalities. The findings of our research suggest that the retinal microvasculature can provide essential data about concurrent cardiac disease status and predict future risk of cardiac-related events.

Predictive value of the coronary artery calcium score and advanced plaque characteristics: Post hoc analysis of the PREDICT registry

BACKGROUND

Whether coronary plaque characteristics assessed in coronary computed tomography angiography (CCTA) in association with the coronary artery calcium score (CACS) have predictive value for coronary events is unclear. We aimed to examine the predictive value of the CACS and plaque characteristics for the occurrence of coronary events.

METHODS

Among 2802 patients who were analyzed in the PREDICT registry, 2083 with suspected coronary artery disease (CAD) were studied using post hoc analysis. High-risk plaques were defined as having ≥2 adverse characteristics, such as low computed tomographic attenuation, positive remodeling, spotty calcification, and napkin-ring sign. An adjudicative composite of coronary events (cardiac death, nonfatal acute coronary syndrome, and coronary revascularization ≥3 months after indexed CCTA) were analyzed.

RESULTS

Seventy-three (3.5%) patients had coronary events and 313 (15.0%) had high-risk plaques. Multivariate Cox proportional hazard analysis showed that high-risk plaques remained an independent predictor of coronary events (adjusted hazard ratio [HR] 1.95, 95% confidence interval [CI] 1.13-3.34, P ​= ​0.0154), as well as the log-transformed CACS (adjusted HR 1.24, 95% CI 1.11-1.39, P ​= ​0.0002) and the presence of obstructive stenosis (adjusted HR 5.63, 95% CI 3.22-10.12, P 0.0001). In subgroup analyses, high-risk plaques were independently predictive only in the low CACS class (<100).

CONCLUSION

This study shows that assessment of adverse features by coronary plaque imaging independently predicts coronary events in patients with suspected CAD and a low CACS. Our findings suggest that the clinical value of high-risk plaques to CACS and stenosis assessment appears marginal.

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.

The effects of endurance exercise on the heart: panacea or poison?

Regular aerobic physical exercise of moderate intensity is undeniably associated with improved health and increased longevity, with some studies suggesting that more is better. Endurance athletes exceed the usual recommendations for exercise by 15-fold to 20-fold. The need to sustain a large cardiac output for prolonged periods is associated with a 10-20% increase in left and right ventricular size and a substantial increase in left ventricular mass. A large proportion of endurance athletes have raised levels of cardiac biomarkers (troponins and B-type natriuretic peptide) and cardiac dysfunction for 24-48 h after events, but what is the relevance of these findings? In the longer term, some endurance athletes have an increased prevalence of coronary artery disease, myocardial fibrosis and arrhythmias. The inherent association between these 'maladaptations' and sudden cardiac death in the general population raises the question of whether endurance exercise could be detrimental for some individuals. However, despite speculation that these abnormalities confer an increased risk of future adverse events, elite endurance athletes have an increased life expectancy compared with the general population.

Scoring of Coronary Artery Disease Characteristics on Coronary CT Angiograms by Using Machine Learning

Background Coronary CT angiography contains prognostic information but the best method to extract these data remains unknown. Purpose To use machine learning to develop a model of vessel features to discriminate between patients with and without subsequent death or cardiovascular events. Performance was compared with that of conventional scores. Materials and Methods Coronary CT angiography was analyzed by radiologists into four features for each of 16 coronary segments. Four machine learning model types were explored. Five conventional vessel scores were computed for comparison including the Coronary Artery Disease Reporting and Data System (CAD-RADS) score. The National Death Index was retrospectively queried from January 2004 through December 2015. Outcomes were all-cause mortality, coronary heart disease deaths, and coronary deaths or nonfatal myocardial infarctions. Score performance was assessed by using area under the receiver operating characteristic curve (AUC). Results Between February 2004 and November 2009, 6892 patients (4452 men [mean age ± standard deviation, 51 years ± 11] and 2440 women [mean age, 57 years ± 12]) underwent coronary CT angiography (median follow-up, 9.0 years; interquartile range, 8.2-9.8 years). There were 380 deaths of all causes, 70 patients died of coronary artery disease, and 43 patients reported nonfatal myocardial infarctions. For all-cause mortality, the AUC was 0.77 (95% confidence interval: 0.76, 0.77) for machine learning (k-nearest neighbors) versus 0.72 (95% confidence interval: 0.72, 0.72) for CAD-RADS (P < .001). For coronary artery heart disease deaths, AUC was 0.85 (95% confidence interval: 0.84, 0.85) for machine learning versus 0.79 (95% confidence interval: 0.78, 0.80) for CAD-RADS (P < .001). When deciding whether to start statins, if the choice is made to tolerate treating 45 patients to be sure to include one patient who will later die of coronary disease, the use of the machine learning score ensures that 93% of patients with events will be administered the drug; if CAD-RADS is used, only 69% will be treated. Conclusion Compared with Coronary Artery Disease Reporting and Data System and other scores, machine learning methods better discriminated patients who subsequently experienced an adverse event from those who did not. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Schoepf and Tesche in this issue.

Long-term risk of cardiovascular events after detecting silent coronary atheromatosis using computed tomography

BACKGROUND

Coronary calcium score (CCS) and coronary computed tomography angiography (CTA) assessments using multidetector computed tomography are invaluable for atheromatosis screening. We studied their usefulness in cardiovascular risk assessments, and compared evaluations using the Systematic COronary Risk Evaluation (SCORE) algorithm with those from CTA and CSS assessments in terms of their ability to predict cardiovascular events in Mediterranean patients.

PATIENTS AND METHODS

Two hundred and sixty-six asymptomatic patients whose mean age was 55.4 years, 89.5% of whom were men, were evaluated using CTA and CCS and followed for more than 10 years. The CTA and CCS risk predictions were compared with those determined using the SCORE algorithm designed for low-risk populations.

RESULTS

Coronary lesions were present in 140 (53.4%) patients. Of the lesions, 17% were noncalcified, 17% were mixed, and 66% were calcified; in addition, 24.2% of the patients who had lesions had cardiovascular events during follow-up (P<0.00001), but just 2.9% of the patients without lesions. Detection of atheromatosis using computed tomography was associated with an increased risk of cardiovascular disease events at more than 10 years [odds ratio (OR): 6.828; 95% confidence interval (CI): 2.001-23.305; P=0.002]. This OR was higher than that obtained for intermediate-risk individuals (OR: 4.818; 95% CI: 1.360-17.075; P=0.015) and lower than that determined for high-risk individuals (OR: 9.395; 95% CI: 2.489-35.460; P=0.001) using the SCORE algorithm, and higher that that determined for CCS assessments (OR: 3.916; 95% CI: 1.572-9.751; P=0.03). More cardiovascular events were associated with higher amounts of calcium.

CONCLUSION

The detection of atheromatosis using the CCS and CTA was associated with an increased risk of cardiovascular events at more than 10 years. CTA and CCS assessments had a higher OR than that associated with assessments of patients at intermediate risk using the SCORE algorithm.

Negative predictive value of stress myocardial perfusion imaging and coronary computed tomography angiography: A meta-analysis

BACKGROUND

Comparing the prognostic value of a negative finding by stress single-photon emission computed tomography myocardial perfusion imaging (MPI) and coronary computed tomography angiography (CCTA) may be useful to evaluate how better identify low-risk patients. We performed a meta-analysis to compare the long-term negative predictive value (NPV) of normal stress MPI and normal CCTA in subjects with suspected coronary artery disease (CAD).

METHODS AND RESULTS

Studies published between January 2000 and November 2016 were identified by database search. We included MPI and CCTA studies that followed-up ≥100 subjects for ≥5 years and providing data on clinical outcome for patients with negative tests. Summary risk estimates for normal perfusion at MPI or <50% coronary stenosis at CCTA were derived in random effect regression analysis, and causes of heterogeneity were determined in meta-regression analysis. We identified 12 eligible articles (6 MPI and 6 CCTA) including 33,129 patients (26,757 in MPI and 6372 in CCTA studies) with suspected CAD. The pooled annualized event rate (AER) for occurrence of hard events (death and nonfatal myocardial infarction) was 1.06 (95% confidence interval, CI 0.49-1.64) in MPI and 0.61 (95% CI 0.35-0.86) in CCTA studies. The pooled NPV was 91% (95% CI 86-96) in MPI and 96 (95% CI 95-98) in CCTA studies. The summary rates between MPI and CCTA were not statistically different. At meta-regression analysis, no significant association between AER and clinical and demographical variables considered was found for overall studies.

CONCLUSIONS

Stress MPI and CCTA have a similar ability to identify low-risk patients with suspected CAD.

Evaluation of Atherosclerotic Plaque in Non-invasive Coronary Imaging

Coronary artery disease (CAD) is the leading cause of morbidity and mortality worldwide. Over the last decade coronary computed tomography angiography (CCTA) has gained wide acceptance as a reliable, cost-effective and non-invasive modality for diagnosis and prognostication of CAD. Use of CCTA is now expanding to characterization of plaque morphology and identification of vulnerable plaque. Additionally, CCTA is developing as a non-invasive modality to monitor plaque progression, which holds future potential in individualizing treatment. In this review, we discuss the role of CCTA in diagnosis and management of CAD. Additionally, we discuss the recent advancements and the potential clinical applications of CCTA in management of CAD.

Low thigh muscle mass is associated with coronary artery stenosis among HIV-infected and HIV-uninfected men: The Multicenter AIDS Cohort Study (MACS)

BACKGROUND

HIV-infected individuals are at increased risk for both sarcopenia and cardiovascular disease. Whether an association between low muscle mass and subclinical coronary artery disease (CAD) exists, and if it is modified by HIV serostatus, are unknown.

METHODS

We performed cross-sectional analysis of 513 male MACS participants (72% HIV-infected) who underwent mid-thigh computed tomography (CT) and non-contrast cardiac CT for coronary artery calcium (CAC) during 2010-2013. Of these, 379 also underwent coronary CT angiography for non-calcified coronary plaque (NCP) and obstructive coronary stenosis ≥50%. Multivariable-adjusted Poisson regression was used to estimate prevalence risk ratios of associations between low muscle mass (<20th percentile of the HIV-uninfected individuals in the sample) and CAC, NCP and obstructive stenosis.

RESULTS

The prevalence of low thigh muscle mass was similar by HIV serostatus (20%). There was no association of low muscle mass with CAC or NCP. However, low thigh muscle mass was significantly associated with a 2.5-fold higher prevalence of obstructive coronary stenosis, after adjustment for demographics and traditional CAD risk factors [PR 2.46 (95% CI 1.51, 4.01)]. This association remained significant after adjustment for adiposity, inflammation, and physical activity. There was no significant interaction by HIV serostatus (p-interaction = 0.90).

CONCLUSIONS

In this exploratory analysis, low thigh muscle mass was significantly associated with subclinical obstructive coronary stenosis. Additional studies involving larger sample sizes and prospective analyses are needed to confirm the potential utility of measuring mid-thigh muscle mass for identifying individuals at increased risk for obstructive CAD who might benefit from more aggressive risk factor management.

Coronary Plaque Progression and Regression in Asymptomatic African American Chronic Cocaine Users With Obstructive Coronary Stenoses: A Preliminary Study

OBJECTIVE

Although rapid progression of coronary atherosclerosis was observed in chronic cocaine users, it is unknown whether reduced cocaine use retards the progression of atherosclerosis. We investigated whether reduced cocaine use over a 12-month period was associated with coronary plaque regression in cocaine users.

METHODS

Fifteen African American chronic cocaine users with previously coronary computed tomography angiography (CCTA)-confirmed >50% coronary stenosis in Baltimore, Maryland, were enrolled in a study to investigate whether reduced cocaine use is associated with changes in coronary plaque burden over a 12-month period of cash-based incentive intervention, which was implemented to systematically reinforce cocaine abstinence. In addition to previous CCTA (preintervention), CCTA was performed at the intervention baseline and at postintervention. Plaque analyses were performed to determine the trajectory of plaque changes in the absence of intervention by comparing the preintervention with the intervention baseline studies; the trajectory of plaque changes associated with the intervention by comparing the intervention baseline with the postintervention studies; and (3) whether reduced cocaine use was independently associated with changes in coronary plaque burden.

RESULTS

During the 12-month cash-based incentive intervention period, cocaine use in participants was lower. The medians of noncalcified plaque indices were 37.8 (interquartile range [IQR] 29.3-44.0), 43.1 (IQR 38.3-49.0), and 38.7 (IQR 31.2-46.8) mm at preintervention, intervention baseline, and postintervention, respectively. Multivariable generalized estimating equation analysis showed that both total plaque and noncalcified plaque indices at preintervention were significantly lowered as compared with intervention baseline levels; both total plaque and noncalcified plaque indices after intervention were significantly lowered as compared with intervention baseline levels; and reduced cocaine use was independently associated with lower total plaque volume index (P < 0.0001) and noncalcified plaque volume index (P = 0.010).

CONCLUSIONS

Our findings suggest that continued cocaine use may be associated with noncalcified plaque progression, whereas reduced cocaine use may be associated with noncalcified plaque regression. Larger studies are needed to confirm these findings.

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.

Poor long-term outcomes in stroke patients with asymptomatic coronary artery disease in heart CT

BACKGROUND AND AIMS

Although stroke patients have a high risk of ischemic heart disease, little information is available on the risk of coronary events in stroke patients with asymptomatic coronary artery disease (CAD). We investigated the long-term vascular outcomes in stroke patients with asymptomatic CAD diagnosed with multi-detector coronary computed tomography (MDCT).

METHODS

This study was a retrospective analysis using a prospective cohort of ischemic stroke patients. We included consecutive stroke patients without history or symptoms of CAD who underwent MDCT. We investigated the long-term risk of major adverse cardiovascular events (MACE: cardiovascular mortality, ischemic stroke, myocardial infarction, unstable angina, and urgent coronary revascularization) and composite of MACE/all-cause mortality/elective coronary revascularization. We further investigated the value of MDCT for MACE prediction.

RESULTS

Among the 1893 included patients, 1349 (71.3%) patients had some degree of CAD and 654 patients (34.5%) had significant (≥50%) CAD. At follow-up (median, 4.4 years), MACE occurred in 230 patients (12.2%). Event rates of MACE increased with the increasing extent of CAD. After adjustment for age, sex, and risk factors, the hazard ratios for MACE in mild CAD, 1-VD, 2-VD, and 3-VD or left main coronary disease were 1.28 (95% confidence interval [CI]: 0.88-1.87), 1.39 (95% CI: 0.90-2.16), 2.22 (95% CI: 1.39-3.55), and 2.91 (95% CI: 1.82-4.65), respectively (no CAD as a reference). Diagnosis of asymptomatic CAD significantly improved the prediction of MACE.

CONCLUSIONS

Asymptomatic CAD detected on MDCT was associated with increased risks of vascular events or deaths in acute stroke patients.

Cardiac SPECT/CCTA hybrid imaging : One answer to two questions?

Noninvasive cardiac imaging has witnessed tremendous advances in the recent past, particularly with regard to coronary computed tomography angiography (CCTA) where substantial improvements in image quality have been achieved while at the same time patients' radiation dose exposure has been reduced to the sub-millisievert range. Similarly, for single-photon emission computed tomography (SPECT) the introduction of novel cadmium-zinc-telluride-based semiconductor detectors has significantly improved system sensitivity and image quality, enabling fast image acquisition within less than 2-3 min or reduction of radiation dose exposure to less than 5 mSv. However, neither imaging modality alone is able to fully cover the two aspects of coronary artery disease (CAD), that is, morphology and function. Both modalities have distinct advantages and shortcomings: While CCTA may prove a superb modality for excluding CAD through its excellent negative predictive value, it does not allow for assessment of hemodynamic relevance if obstructive coronary lesions are detected. Conversely, SPECT myocardial perfusion imaging cannot provide any information on the presence or absence of subclinical coronary atherosclerosis. This article aims to highlight the great potential of cardiac hybrid imaging that allows for a comprehensive evaluation of CAD through combination of both morphological and functional information by fusing SPECT with CCTA.

Prognostic Value of Noninvasive Cardiovascular Testing in Patients With Stable Chest Pain: Insights From the PROMISE Trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain)

BACKGROUND

Optimal management of patients with stable chest pain relies on the prognostic information provided by noninvasive cardiovascular testing, but there are limited data from randomized trials comparing anatomic with functional testing.

METHODS

In the PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), patients with stable chest pain and intermediate pretest probability for obstructive coronary artery disease (CAD) were randomly assigned to functional testing (exercise electrocardiography, nuclear stress, or stress echocardiography) or coronary computed tomography angiography (CTA). Site-based diagnostic test reports were classified as normal or mildly, moderately, or severely abnormal. The primary end point was death, myocardial infarction, or unstable angina hospitalizations over a median follow-up of 26.1 months.

RESULTS

Both the prevalence of normal test results and incidence rate of events in these patients were significantly lower among 4500 patients randomly assigned to CTA in comparison with 4602 patients randomly assigned to functional testing (33.4% versus 78.0%, and 0.9% versus 2.1%, respectively; both P<0.001). In CTA, 54.0% of events (n=74/137) occurred in patients with nonobstructive CAD (1%-69% stenosis). Prevalence of obstructive CAD and myocardial ischemia was low (11.9% versus 12.7%, respectively), with both findings having similar prognostic value (hazard ratio, 3.74; 95% confidence interval [CI], 2.60-5.39; and 3.47; 95% CI, 2.42-4.99). When test findings were stratified as mildly, moderately, or severely abnormal, hazard ratios for events in comparison with normal tests increased proportionally for CTA (2.94, 7.67, 10.13; all P<0.001) but not for corresponding functional testing categories (0.94 [P=0.87], 2.65 [P=0.001], 3.88 [P<0.001]). The discriminatory ability of CTA in predicting events was significantly better than functional testing (c-index, 0.72; 95% CI, 0.68-0.76 versus 0.64; 95% CI, 0.59-0.69; P=0.04). If 2714 patients with at least an intermediate Framingham Risk Score (>10%) who had a normal functional test were reclassified as being mildly abnormal, the discriminatory capacity improved to 0.69 (95% CI, 0.64-0.74).

CONCLUSIONS

Coronary CTA, by identifying patients at risk because of nonobstructive CAD, provides better prognostic information than functional testing in contemporary patients who have stable chest pain with a low burden of obstructive CAD, myocardial ischemia, and events.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01174550.

Long-term prognostic performance of low-dose coronary computed tomography angiography with prospective electrocardiogram triggering

OBJECTIVES

To assess long-term prognosis after low-dose 64-slice coronary computed tomography angiography (CCTA) using prospective electrocardiogram-triggering.

METHODS

We included 434 consecutive patients with suspected or known coronary artery disease referred for low-dose CCTA. Patients were classified as normal, with non-obstructive or obstructive lesions, or previously revascularized. Coronary artery calcium score (CACS) was assessed in 223 patients. Follow-up was obtained regarding major adverse cardiac events (MACE): cardiac death, myocardial infarction and elective revascularization. We performed Kaplan-Meier analysis and Cox regressions.

RESULTS

Mean effective radiation dose was 1.7 ± 0.6 mSv. At baseline, 38% of patients had normal arteries, 21% non-obstructive lesions, 32% obstructive stenosis and 8% were revascularized. Twenty-nine patients (7%) were lost to follow-up. After a median follow-up of 6.1 ± 0.6 years, MACE occurred in 0% of patients with normal arteries, 6% with non-obstructive lesions, 30% with obstructive stenosis and 39% of those revascularized. MACE occurrence increased with increasing CACS (P < 0.001), but 4% of patients with CACS = 0 experienced MACE. Multivariate Cox regression identified obstructive stenosis, lesion burden in CCTA and CACS as independent MACE predictors (P ≤ 0.001).

CONCLUSION

Low-dose CCTA with prospective electrocardiogram-triggering has an excellent long-term prognostic performance with a warranty period >6 years for patients with normal coronary arteries.

KEY POINTS

• Coronary CT angiography (CCTA) has an excellent long-term prognostic performance. • CCTA can accurately stratify cardiac risk according to coronary lesion severity. • A normal CCTA predicts freedom from cardiac events for >6 years. • Patients with a coronary calcium score of 0 may experience cardiac events. • CCTA allows for reclassification of cardiac risk compared with ESC SCORE.

Coronary computed tomography angiography derived risk score in predicting cardiac events

BACKGROUND

We evaluated the prognostic value of an integrated atherosclerosis risk score combining the markers of coronary plaque burden, location and composition as assessed by computed tomography angiography (CTA).

METHODS

922 consecutive patients underwent CTA for suspected coronary artery disease (CAD). Patients without atherosclerosis (n = 261) and in whom quantitative CTA analysis was not feasible due to image quality, step-artefacts or technical factors related to image acquisition or data storage (n = 153) were excluded. Thus, final study group consisted of 508 patients aged 63 ± 9 years. Coronary plaque location, severity and composition for each coronary segment were identified using automated CTA quantification software and integrated in a single CTA score (0-42). Adverse events (AE) including death, myocardial infarction (MI) and unstable angina (UA) were obtained from the national healthcare statistics.

RESULTS

There were a total of 20 (4%) AE during a median follow-up of 3.6 years (9 deaths, 5 MI and 6 UA). The CTA risk score was divided into tertiles: 0-6.7, 6.8-14.8 and > 14.8, respectively. All MI (n = 5) and most of the other AE occurred in the highest risk score tertile (3 vs. 3 vs. 14, p = 0.002). After correction for age and gender, the CTA risk score remained independently associated with AE.

CONCLUSIONS

Comprehensive CTA risk score integrating the location, burden and composition of coronary atherosclerosis predicts future cardiac events in patients with suspected CAD.

Factors Associated With Coronary Artery Disease Progression Assessed By Serial Coronary Computed Tomography Angiography

Background

Coronary computed tomography angiography (CCTA) allows for noninvasive coronary artery disease (CAD) phenotyping. Factors related to CAD progression are epidemiologically valuable.

Objective

To identify factors associated with CAD progression in patients undergoing sequential CCTA testing.

Methods

We retrospectively analyzed 384 consecutive patients who had at least two CCTA studies between December 2005 and March 2013. Due to limitations in the quantification of CAD progression, we excluded patients who had undergone surgical revascularization previously or percutaneous coronary intervention (PCI) between studies. CAD progression was defined as any increase in the adapted segment stenosis score (calculated using the number of diseased segments and stenosis severity) in all coronary segments without stent (in-stent restenosis was excluded from the analysis). Stepwise logistic regression was used to assess variables associated with CAD progression.

Results

From a final population of 234 patients, a total of 117 (50%) had CAD progression. In a model accounting for major CAD risk factors and other baseline characteristics, only age (odds ratio [OR] 1.04, 95% confidence interval [95%CI] 1.01-1.07), interstudy interval (OR 1.03, 95%CI 1.01-1.04), and past PCI (OR 3.66, 95%CI 1.77-7.55) showed an independent relationship with CAD progression.

Conclusions

A history of PCI with stent placement was independently associated with a 3.7-fold increase in the odds of CAD progression, excluding in-stent restenosis. Age and interstudy interval were also independent predictors of progression.

Left main coronary artery stenosis: severity evaluation and implications for management

INTRODUCTION

The significant stenosis of the left main coronary artery is associated with poor outcomes and is considered a strong indication for revascularization. However, deciding whether the stenosis is significant can sometimes be challenging, especially when the degree of stenosis is intermediate, and can necessitate additional tests and imaging modalities. Areas covered: We did a literature search using keywords like 'left main', 'imaging', 'intravascular ultrasound', 'fractional flow reserve', 'computed tomographic angiography' and 'magnetic resonance imaging'. The most commonly used methods for better characterizing intermediate left main coronary stenoses are intravascular ultrasound and fractional flow reserve, while optical coherence tomography is the newer technique that provides better images, but for which not as much data is available. The noninvasive techniques are coronary computed tomographic angiography and, to a lesser degree, coronary magnetic resonance imaging. Expert commentary: Accurately determining the severity of left main coronary stenosis can mean the difference between a major intervention and conservative therapy. The reviewed newer imaging modalities give us greater confidence that patients with left main stenosis are assigned to the right treatment modality.

Increased Risk of Cardiovascular Events in Stroke Patients Who had Not Undergone Evaluation for Coronary Artery Disease

PURPOSE

Although asymptomatic coronary artery occlusive disease is common in stroke patients, the long-term advantages of undergoing evaluation for coronary arterial disease using multi-detector coronary computed tomography (MDCT) have not been well established in stroke patients. We compared long-term cardio-cerebrovascular outcomes between patients who underwent MDCT and those who did not.

MATERIALS AND METHODS

This was a retrospective study in a prospective cohort of consecutive ischemic stroke patients. Of the 3117 patients who were registered between July 2006 and December 2012, MDCT was performed in 1842 patients [MDCT (+) group] and not in 1275 patients [MDCT (-) group]. Occurrences of death, cardiovascular events, and recurrent stroke were compared between the groups using Cox proportional hazards models and propensity score analyses.

RESULTS

During the mean follow-up of 38.0±24.8 months, 486 (15.6%) patients died, recurrent stroke occurred in 297 (9.5%), and cardiovascular events occurred in 60 patients (1.9%). Mean annual risks of death (9.34% vs. 2.47%), cardiovascular events (1.2% vs. 0.29%), and recurrent stroke (4.7% vs. 2.56%) were higher in the MDCT (-) group than in the MDCT (+) group. The Cox proportional hazards model and the five propensity score-adjusted models consistently demonstrated that the MDCT (-) group was at a high risk of cardiovascular events (hazard ratios 3.200, 95% confidence interval 1.172-8.735 in 1:1 propensity matching analysis) as well as death. The MDCT (-) group seemed to also have a higher risk of recurrent stroke.

CONCLUSION

Acute stroke patients who underwent MDCT experienced fewer deaths, cardiovascular events, and recurrent strokes during follow-up.

Prognostic Value of Coronary Computed Tomography Angiography in Patients With Diabetes: A Meta-analysis

OBJECTIVE

The usefulness of coronary computed tomography angiography (CTA) for the evaluation of coronary artery disease (CAD) in patients with diabetes is ambiguous. We therefore performed a meta-analysis of studies reporting event rates and hazard ratios (HR) to determine the prognostic value of CTA in this patient population.

RESEARCH DESIGN AND METHODS

We searched PubMed and Embase up to November 2015. Study subjects' characteristics, events (all-cause mortality or cardiac death, nonfatal myocardial infarction, unstable angina pectoris, stroke, revascularization), and events excluding revascularization were collected. We calculated the prevalence of obstructive and nonobstructive CAD on CTA, annualized event rates, and pooled unadjusted and adjusted HR using a generic inverse random model.

RESULTS

Eight studies were eligible for inclusion into this meta-analysis, with 6,225 participants (56% male; weighted age, 61 years) with a follow-up period ranging from 20 to 66 months. The prevalence of obstructive CAD, nonobstructive CAD, and no CAD was 38%, 36%, and 25%, respectively. The annualized event rate was 17.1% for obstructive CAD, 4.5% for nonobstructive CAD, and 0.1% for no CAD. Obstructive and nonobstructive CAD were associated with an increased HR of 5.4 and 4.2, respectively. A higher HR for obstructive CAD was observed in studies including revascularization compared with those that did not (7.3 vs. 3.7, P = 0.124).

CONCLUSIONS

CTA in patients with diabetes allows for safely ruling out future events, and the detection of CAD could allow for the identification of high-risk patients in whom aggressive risk factor modification, medical surveillance, or elective revascularization could potentially improve survival.

Sex Differences in Functional and CT Angiography Testing in Patients With Suspected Coronary Artery Disease

BACKGROUND

Although risk stratification is an important goal of cardiac noninvasive tests (NITs), few contemporary data exist on the prognostic value of different NITs according to patient sex.

OBJECTIVES

The goal of this study was to compare the results and prognostic information derived from anatomic versus stress testing in stable men and women with suspected coronary artery disease.

METHODS

In 8,966 patients tested at randomization (4,500 to computed tomography angiography [CTA], 52% female; 4,466 to stress testing, 53% female), we assessed the relationship between sex and NIT results and between sex and a composite of death, myocardial infarction, or unstable angina hospitalization.

RESULTS

In women, a positive CTA (≥70% stenosis) was less likely than a positive stress test result (8% vs. 12%; adjusted odds ratio: 0.67). Compared with negative test results, a positive CTA was more strongly associated with subsequent clinical events than a positive stress test result (CTA-adjusted hazard ratio of 5.86 vs. stress-adjusted hazard ratio of 2.27; adjusted p = 0.028). Men were more likely to have a positive CTA than a positive stress test result (16% vs. 14%; adjusted odds ratio: 1.23). Compared with negative test results, a positive CTA was less strongly associated with subsequent clinical events than a positive stress test result in men, although this difference was not statistically significant (adjusted p = 0.168). Negative CTA and stress test results were equally likely to predict an event in both sexes. A significant interaction between sex, NIT type, and test result (p = 0.01) suggests that sex and NIT type jointly influence the relationship between test result and clinical events.

CONCLUSIONS

The prognostic value of an NIT result varies according to test type and patient sex. Women seem to derive more prognostic information from a CTA, whereas men tend to derive similar prognostic value from both test types.

Long-term prognostic value of stress myocardial perfusion imaging and coronary computed tomography angiography: A meta-analysis

BACKGROUND

We conducted a meta-analysis to compare the long-term prognostic value of stress single-photon emission computed tomography myocardial perfusion imaging (MPI) and coronary computed tomography angiography (CCTA) for adverse cardiovascular events in subjects with suspected or known coronary artery disease.

METHODS AND RESULTS

We searched PubMed, Cochrane, Web of Science, and Scopus database between January 2000 and December 2014 for stress MPI and CCTA studies that followed up ≥ 100 subjects for ≥ 2.5 years and provided the unadjusted and/or adjusted hazard ratio (HR) at Cox regression analysis. Summary risk estimates for abnormal perfusion at MPI or ≥ 50% coronary stenosis at CCTA were derived in random effect regression analysis, and causes of heterogeneity were determined in meta-regression analysis. We identified 21 eligible articles (10 MPI and 11 CCTA) including 25,258 participants (13,484 in MPI and 11,774 in CCTA studies) with suspected or known coronary artery disease. Among the included publications, 8 MPI and 8 CCTA studies reported the HR for the occurrence of hard events (death and nonfatal myocardial infarction). The pooled HR was comparable for MPI and CCTA studies. The HR for the occurrence of a combined endpoint including revascularization as event was reported in 4 MPI and 6 CCTA studies. The pooled HR was higher for CCTA compared to MPI (P < .05) also when only MPI and CCTA studies with limited representation of prior CAD were considered.

CONCLUSIONS

The long-term prognostic value of MPI and CCTA for the occurrence of hard events is similar. However, the association between event-free survival and CCTA is higher than MPI when coronary revascularization is included in the endpoint.

Combined non-invasive assessment of endothelial shear stress and molecular imaging of inflammation for the prediction of inflamed plaque in hyperlipidaemic rabbit aortas

AIMS

To evaluate the incremental value of low endothelial shear stress (ESS) combined with high-resolution magnetic resonance imaging (MRI)- and computed tomography angiography (CTA)-based imaging for the prediction of inflamed plaque.

METHODS AND RESULTS

Twelve hereditary hyperlipidaemic rabbits underwent quantitative analysis of plaque in the thoracic aorta with 256-slice CTA and USPIO-enhanced (ultra-small superparamagnetic nanoparticles, P904) 1.5-T MRI at baseline and at 6-month follow-up. Computational fluid dynamics using CTA-based 3D reconstruction of thoracic aortas identified the ESS patterns in the convex and concave curvature subsegments of interest. Subsegments with low baseline ESS exhibited significant increase in wall thickness and plaque inflammation by MRI, in non-calcified plaque burden by CTA, and developed increased plaque size, lipid and inflammatory cell accumulation (high-risk plaque features) at follow-up by histopathology. Multiple regression analysis identified baseline ESS and inflammation by MRI to be independent predictors of plaque progression, while receiver operating curve analysis revealed baseline ESS alone or in combination with inflammation by MRI as the strongest predictor for augmented plaque burden and inflammation (low ESS at baseline: AUC = 0.84, P < 0.001; low ESS and inflammation by molecular MRI at baseline: AUC = 0.89, P < 0.001).

CONCLUSION

Low ESS predicts progression of plaque burden and inflammation as assessed by non-invasive USPIO-enhanced MRI. Combined non-invasive assessment of ESS and imaging of inflammation may serve to predict plaque with high-risk features.

Use of Coronary Computed Tomographic Angiography Findings to Modify Statin and Aspirin Prescription in Patients With Acute Chest Pain

Coronary CT angiography (CCTA) is used in patients with low-intermediate chest pain presenting to the emergency department for its reliability in excluding acute coronary syndrome (ACS). However, its influence on medication modification in this setting is unclear. We sought to determine whether knowledge of CCTA-based coronary artery disease (CAD) was associated with change in statin and aspirin prescription. We used the CCTA arm of the Rule Out Myocardial Infarction using Computed Angiographic Tomography II multicenter, randomized control trial (R-II) and comparison cohort from the observational Rule Out Myocardial Infarction using Computed Angiographic Tomography I cohort (R-I). In R-II, subjects were randomly assigned to CCTA to guide decision making, whereas in R-I patients underwent CCTA with results blinded to caregivers and managed according to standard care. Our final cohort consisted of 277 subjects from R-I and 370 from R-II. ACS rate was similar (6.9% vs 6.2% respectively, p = 0.75). For subjects with CCTA-detected obstructive CAD without ACS, initiation of statin was significantly greater after disclosure of CCTA results (0% in R-I vs 20% in R-II, p = 0.009). Conversely, for subjects without CCTA-detected CAD, aspirin prescription was lower with disclosure of CCTA results (16% in R-I vs 4.8% in R-II, p = 0.001). However, only 68% of subjects in R-II with obstructive CAD were discharged on statin and 65% on aspirin. In conclusion, physician knowledge of CCTA results leads to improved alignment of aspirin and statin with the presence and severity of CAD although still many patients with CCTA-detected CAD are not discharged on aspirin or statin. Our findings suggest opportunity for practice improvement when CCTA is performed in the emergency department.

2013 ACC/AHA versus 2004 NECP ATP III Guidelines in the Assignment of Statin Treatment in a Korean Population with Subclinical Coronary Atherosclerosis

Background

The usefulness of the 2013 ACC/AHA guidelines for the management of blood cholesterol in the Asian population remains controversial. In this study, we investigated whether eligibility for statin therapy determined by the 2013 ACC/AHA guidelines is better aligned with the presence of subclinical coronary atherosclerosis detected by CCTA (coronary computed tomography angiography) compared to the previously recommended 2004 NCEP ATP III guidelines.

Methods

We collected the data from 5,837 asymptomatic subjects who underwent CCTA using MDCT during routine health examinations. Based on risk factor assessment and lipid data, we determined guideline-based eligibility for statin therapy according to the 2013 ACC/AHA and 2004 NCEP ATP III guidelines. We defined the presence and severity of subclinical coronary atherosclerosis detected in CCTA according to the presence of significant coronary artery stenosis (defined as >50% stenosis), plaques, and the degree of coronary calcification.

Results

As compared to the 2004 ATP III guidelines, a significantly higher proportion of subjects with significant coronary stenosis (61.8% vs. 33.8%), plaques (52.3% vs. 24.7%), and higher CACS (CACS >100, 63.6% vs. 26.5%) was assigned to statin therapy using the 2013 ACC/AHA guidelines (P < .001 for all variables). The area under the curves of the pooled cohort equation of the new guidelines in detecting significant stenosis, plaques, and higher CACS were significantly higher than those of the Framingham risk calculator.

Conclusions

Compared to the previous ATP III guidelines, the 2013 ACC/AHA guidelines were more sensitive in identifying subjects with subclinical coronary atherosclerosis detected by CCTA in an Asian population.

Prognostic Value of Renal Function for Cardiac Events in Patients Without Significant Stenosis on Coronary Computed Tomography Angiography

This study was conducted to determine clinical parameters predicting future major adverse cardiovascular events (MACEs) in patients without significant stenosis on coronary computed tomographic angiography (CCTA). A total of 625 patients with suspected coronary artery disease (CAD) who underwent CCTA that revealed insignificant (< 50%) CAD was reviewed in three cardiac centers. The MACEs including cardiac death, non-fatal myocardial infarction (MI), unstable angina and late (> 90 days after CCTA) revascularization were assessed. During the mean follow-up period of 819 ± 529 days (median 837 days), there were 28 cases of MACEs (4.5%). In multivariable Cox regression analysis, independent predictors for MACEs were male sex (hazard ratio [HR], 2.40; 95% confidence interval [CI], 1.01-5.69; P = 0.046) and low estimated creatinine clearance (eCCr) (< 60 mL/min/1.73 m(2)) (HR, 3.07; 95% CI, 1.22-7.74; P = 0.017). Low eCCr was the only independent predictor for hard events including cardiac death and MI (HR, 17.6, 95% CI, 1.44-215.7; P = 0.025). In conclusion, renal function is an independent predictor for cardiovascular events among patients without significant CAD by CCTA. Careful monitoring and preventive strategy are warranted in patients with impaired renal function even without significant CAD.

Progression of coronary artery disease. Experience with computed tomography

Coronary artery disease (CAD) begins with asymptomatic atherosclerotic changes in the vessel wall. Gradual or abrupt progression of some of these early lesions eventually leads to symptomatic luminal narrowing. Coronary computed tomography angiography (CTA) allows for a minimally invasive assessment of these wall changes and of the severity of luminal narrowing, and is thus an attractive method for assessing progression/regression. However, because of the associated radiation exposure and concern about false-positive findings, CTA is not recommended as a clinical screening test. Owing to the significantly lower spatial resolution compared with invasive modalities, its application as a tool for clinical progression/regression trials is limited. Therefore, while there are extensive data from both CT coronary artery calcium scoring and CTA studies demonstrating the prognostic value of luminal stenosis as well as the extent and characteristics of plaque, data describing progression/regression are limited.