Prognostic value of noninvasive combined anatomic/functional assessment by cardiac CT in patients with suspected coronary artery disease - Comparison with invasive coronary angiography and nuclear myocardial perfusion imaging for the five-year-follow up of the CORE320 multicenter study

Should we choose CT angiography first instead of SPECT/PET first for the diagnosis and management of coronary artery disease?

In patients presenting with chest pain, current guidelines recommend the use of coronary computed tomography angiography and single-photon emission tomography/positron emission tomography, both with equal class 1 indication and level of evidence A. There is no clear recommendation on which test should be used as a first-line test. The choice of the test should be based on individualized clinical risk assessment, patient characteristics, local expertise/availability, and patient preferences. In this context, it is fair to ask which non-invasive imaging test to choose. The debate reproduced in this article answers this question by summarizing the considerations in selecting present state-of-the-art criteria of the right test for the right patient to ensure efficient resource utilization, minimize unnecessary testing, and maximize diagnostic accuracy and therapeutic efficacy.

Coronary artery disease grading by cardiac CT for predicting outcome in patients with stable angina

BACKGROUND

The coronary atheroma burden drives major adverse cardiovascular events (MACE) in patients with suspected coronary heart disease (CHD). However, a consensus on how to grade disease burden for effective risk stratification is lacking. The purpose of this study was to compare the effectiveness of common CHD grading tools to risk stratify symptomatic patients.

METHODS

We analyzed the 5-year outcome of 381 prospectively enrolled patients in the CORE320 international, multicenter study using baseline clinical and cardiac computer-tomography (CT) imaging characteristics, including coronary artery calcium score (CACS), percent atheroma volume, "high-risk" plaque, disease severity grading using the CAD-RADS, and two simplified CAD staging systems. We applied Cox proportional hazard models and area under the curve (AUC) analysis to predict MACE or hard MACE, defined as death, myocardial infarction, or stroke. Analyses were stratified by a history of CHD. Additional forward selection analysis was performed to evaluate incremental value of metrics.

RESULTS

Clinical characteristics were the strongest predictors of MACE in the overall cohort. In patients without history of CHD, CACS remained the only independent predictor of MACE yielding an AUC of 73 (CI 67-79) vs. 64 (CI 57-70) for clinical characteristics. Noncalcified plaque volume did not add prognostic value. Simple CHD grading schemes yielded similar risk stratification as the CAD-RADS classification. Forward selection analysis confirmed prominent role of CACS and revealed usefulness of functional testing in subgroup with known CHD.

CONCLUSION

In patients referred for invasive angiography, a history of CHD was the strongest predictor of MACE. In patients without history of CHD, a coronary calcium score yielded at least equal risk stratification vs. more complex CHD grading.

Comparison of prognosis between coronary computed tomography angiography versus invasive coronary angiography for stable coronary artery disease: a systematic review and meta-analysis

Background

The impact of using invasive coronary angiography (ICA) or coronary computed tomography angiography (CCTA) as an initial examination on the incidence of major adverse cardiovascular events (MACEs) in patients with stable coronary artery disease and the occurrence of major operation-related complications is uncertain.

Objective

This study aimed to explore the effects of ICA vs. CCTA on MACEs, all-cause death, and major operation-related complications.

Methods

A systematic search of electronic databases (PubMed and Embase) was conducted for randomized controlled trials and observational studies comparing MACEs between ICA and CCTA from January 2012 to May 2022. The primary outcome measure was analyzed using a random-effects model as a pooled odds ratio (OR). The main observations were MACEs, all-cause death, and major operation-related complications.

Results

A total of six studies, comprising 26,548 patients, met the inclusion criteria (ICA n = 8,472; CCTA n = 18,076). There were statistically significant differences between ICA and CCTA for MACE [OR 1.37; 95% confidence interval (CI), 1.06-1.77; p = 0.02], all-cause death (OR 1.56; 95% CI, 1.38-1.78; p < 0.00001), and major operation-related complications (OR 2.10; 95% CI, 1.23-3.61; p = 0.007) among patients with stable coronary artery disease. Subgroup analysis demonstrated statistically significant results in the impact of ICA or CCTA on MACEs according to the length of follow-up. Compared to CCTA, ICA was related to a higher incidence of MACEs in the subgroup with a short follow-up (≤3 years) (OR 1.74; 95% CI, 1.54-1.96; p < 0.00001).

Conclusions

Among patients with stable coronary artery disease, an initial examination with ICA was significantly associated with the risk of MACEs, all-cause death, and major procedure-related complications compared to CCTA in this meta-analysis.

Computed tomographic angiography in coronary artery disease

Coronary computed tomographic angiography (CCTA) is becoming the first-line investigation for establishing the presence of coronary artery disease and, with fractional flow reserve (FFRCT), its haemodynamic significance. In patients without significant epicardial obstruction, its role is either to rule out atherosclerosis or to detect subclinical plaque that should be monitored for plaque progression/regression following prevention therapy and provide risk classification. Ischaemic non-obstructive coronary arteries are also expected to be assessed by non-invasive imaging, including CCTA. In patients with significant epicardial obstruction, CCTA can assist in planning revascularisation by determining the disease complexity, vessel size, lesion length and tissue composition of the atherosclerotic plaque, as well as the best fluoroscopic viewing angle; it may also help in selecting adjunctive percutaneous devices (e.g., rotational atherectomy) and in determining the best landing zone for stents or bypass grafts.

Prognostic value of coronary computed tomography angiography compared to radionuclide myocardial perfusion imaging in patients With coronary stents

Objectives

The aim of this study is to compare the prognostic value of coronary computed tomography angiography (CCTA) with single-photon emission computed tomography (SPECT) in predicting cardiovascular events in patients with stents.

Design

Retrospective analysis.

Setting

University Hospital, London, Ontario Canada.

Participants

Between January 2007 and December 2018, 119 patients post-percutaneous coronary intervention (PCI) who were referred for hybrid imaging with CTA and 2-day rest/stress SPECT were enrolled.

Primary and secondary outcome measures

Patients were followed for any major adverse cardiovascular event (MACE) including: All-cause mortality, Non-fatal myocardial infarction (MI), Unplanned revascularization, Cerebrovascular accident and hospitalization for arrhythmia or heart failure. We define hard cardiac events (HCE) as: cardiac death, non-fatal MI or unplanned revascularization. We used two cut-off values to define obstructive lesions with CCTA ≥50% and ≥70% in any coronary segment. SPECT scan defined as abnormal in the presence of &gt;5% reversible myocardial perfusion defect.

Results

During the follow-up period of 7.2 ± 3.4 years. 45/119 (37.8%) patients experienced 57 MACE: Ten deaths (2 cardiac deaths and 8 of non-cardiac deaths), 29 acute coronary syndrome including non-fatal MI (25 required revascularization), 7 hospitalizations for heart failure, 6 cerebrovascular accidents and 5 new atrial fibrillation. 31 HCEs were reported. Cox regression analysis showed that obstructive coronary stenosis (≥50% and ≥70%) and abnormal SPECT were associated of MACE (p = 0.037, 0.018 and 0.026), respectively. In contrast, HCEs were significantly associated with obstructive coronary stenosis of ≥50% and ≥70% with p = 0.004 and p = 0.007, respectively. In contrast, abnormal SPECT was a nonsignificant predictor of HCEs (p = 0.062).

Conclusion

Obstructive coronary artery stenosis on CCTA can predict MACE and HCE. However, abnormal SPECT can only predict MACE but not HCE in patients post-PCI with a follow-up period of approximately 7 years.

Prognostic Nutritional Index and Major Cardiovascular Events in Patients Undergoing Invasive Coronary Angiography: A Clinical Retrospective Study

We aimed to examine whether prognostic nutritional index (PNI) could serve as an auxiliary predictor for major cardiovascular events (MCEs) in patients undergoing invasive coronary angiography (ICA). A total of 485 participants were enrolled, divided into low-PNI (≥47.40) and high-PNI (<47.40) groups. ICA determined the stenotic vessels of coronary artery disease. The primary outcome was incidental MCEs, a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, or rehospitalization of in-stent restenosis. There were 47 (9.69%) MCEs during the 3.78-years follow-up. The cumulative incidence of MCEs was significantly higher in the low-PNI patients compared with the high-PNI patients (17.07% vs. 7.18%, p = 0.001). Malnutrition risk (low PNI) was significantly and independently associated with a higher risk of MCEs (hazard ratios: 2.593, 95% confidence intervals [CI]: 1.418−4.742). Combined use of the number of stenotic vessels with malnutrition risk showed a higher capacity to predict the MCEs than the presence of stenotic vessels alone (areas under the receiver operator characteristic curve: 0.696 [95% CI, 0.618−0.775] vs. 0.550 [95% CI, 0.466−0.633], p = 0.013). In conclusion, lower PNI levels may predict a higher risk of cardiovascular events in patients undergoing ICA, which supports the necessity of the risk assessment of nutrition status and guide the clinical treatment on strengthening nutritional support before ICA is performed, as well as nutritional intervention after ICA.

The Journal of cardiovascular computed tomography: A year in review 2021

This review aims to summarize original articles published in the Journal of Cardiovascular Computed Tomography (JCCT) for the year 2021, focusing on those that had the most scientific and educational impact. The JCCT continues to expand; the number of submissions, published manuscripts, cited articles, article downloads, social media presence, and impact factor continues to increase. The articles selected by the Editorial Board of the JCCT in this review focus on coronary artery disease, coronary physiology, structural heart disease, and technical advances in cardiovascular CT. In addition, we highlight key consensus documents and guidelines published in the Journal in 2021. The Journal recognizes the tremendous work done by each author and reviewer this year - thank you.

Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part II

Cardiac computed tomography (CT) was initially developed as a non-invasive diagnostic tool to detect and quantify coronary stenosis. Thanks to the rapid technological development, cardiac CT has become a comprehensive imaging modality which offers anatomical and functional information to guide patient management. This is the second of two complementary documents endorsed by the European Association of Cardiovascular Imaging aiming to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. In this article, emerging CT technologies and biomarkers, such as CT-derived fractional flow reserve, perfusion imaging, and pericoronary adipose tissue attenuation, are described. In addition, the role of cardiac CT in the evaluation of atherosclerotic plaque, cardiomyopathies, structural heart disease, and congenital heart disease is revised.