Pericoronary Adipose Tissue Attenuation in Patients With Acute Coronary Syndrome Versus Stable Coronary Artery Disease

P2Y12 Inhibitor Monotherapy After Short-Term Dual Antiplatelet Therapy in Acute Coronary Syndrome

Recent studies have shown similar safety and efficacy of short-term dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor (P2Y12i) monotherapy when compared with standard DAPT. However, the optimal DAPT duration and regimen in acute coronary syndrome (ACS) patients who underwent percutaneous coronary intervention is still unclear. Online databases were searched for randomized controlled trials evaluating P2Y12i monotherapy after short DAPT (≤3 months) versus standard DAPT (≥12 months) in ACS patients. The outcomes of interest were all-cause death, cardiovascular death, myocardial infarction, stent thrombosis, target-vessel revascularization, and major bleeding. Random-effects model was used to calculate pooled odds ratios (OR) and 95% confidence intervals (CI). Six randomized controlled trials with a total of 23,884 patients (n = 11,904 P2Y12i monotherapy, n = 11,980 standard DAPT) were included. Compared with standard DAPT, P2Y12i monotherapy after short DAPT was associated with similar odds of all-cause death (OR 0.86, 95% CI 0.65 to 1.12, p = 0.26) and cardiovascular death (OR 0.75, 95% CI 0.43 to 1.29, p = 0.29) at 1 year. Similarly, there were no significant differences in rates of myocardial infarction (OR 1.09, 0.83 to 1.43, p = 0.53), stent thrombosis (OR 1.09, 95% CI 0.71 to 1.67, p = 0.70) and target-vessel revascularization (OR 0.81, 95% CI 0.65 to 1.01, p = 0.07) between the P2Y12i monotherapy and standard DAPT arms. The P2Y12i monotherapy group had significantly lower major bleeding (OR 0.49, 95% CI 0.38 to 0.64, p < 0.001) when compared with standard DAPT. In conclusion, in patients with ACS who underwent percutaneous coronary intervention, P2Y12i monotherapy after short DAPT significantly reduces bleeding without increasing ischemic risk when compared with standard DAPT therapy.

Prognostic value of serial coronary computed tomography angiography-derived perivascular fat-attenuation index and plaque volume in patients with suspected coronary artery disease

AIMS

To investigate the prognostic value of serial coronary computed tomography angiography (CCTA) derived plaque information, fractional flow reserve (CT-FFR), and perivascular fat-attenuation index (FAI) on major adverse cardiac events (MACE) in patients with suspected coronary artery disease.

MATERIALS AND METHODS

A total of 252 patients who underwent serial CCTA between January 2018 and December 2021 and were followed until June 2022. MACE were recorded. The analysis indexes included percent diameter stenosis (%DS), lesion length, plaque volume, CT-FFR, and FAI, with an emphasis on their changes between the baseline and follow-up CCTAs. Multivariate regression analysis were employed to identify independent risk factors for MACE.

RESULTS

After a median follow-up of 48-month, MACE occurred in 32 patients (12.7%). Patients with MACE displayed more severe stenosis, longer lesions, and larger plaque volumes in both baseline and follow-up CCTAs compared with no-MACE patients (all P<0.05). Patients with MACE displayed more severe stenosis, longer lesion, and larger plaque volume in both baseline and follow-up CCTAs compared with no-MACE patients. In addition, MACE patients also showed lower CT-FFR and higher △CT-FFR. Although FAI was significantly higher in MACE patients at baseline CCTA, FAI was notably increased in MACE patients, and decreased in the no-MACE patients (all P<0.05). Logistic regression analysis showed that ΔFAI, %DS, and plaque volume were independent predictors of MACE, with ΔFAI being the most significant (OR: 16.725, P<0.000). A multivariable model showed a significantly improved C-index of 0.903 (95% confidence interval: 0.836-0.970) for MACE prediction, when compared with single index alone.

CONCLUSIONS

Serial CCTA-derived ΔFAI, %DS, and plaque volume are crucial independent predictors of MACE in patients with suspected coronary artery disease, highlighting the importance of CCTA in patient risk stratification and prognostic assessment.

CT pericoronary adipose tissue density predicts coronary allograft vasculopathy and adverse clinical outcomes after cardiac transplantation

AIMS

To assess pericoronary adipose tissue (PCAT) density on Coronary Computed Tomography Angiography (CCTA) as a marker of inflammatory disease activity in coronary allograft vasculopathy (CAV).

METHODS AND RESULTS

PCAT density, lesion volumes, and total vessel volume-to-myocardial mass ratio (V/M) were retrospectively measured in 126 CCTAs from 94 heart transplant patients (mean age 49 [SD 14.5] years, 40% female) who underwent imaging between 2010 to 2021; age and sex-matched controls; and patients with atherosclerosis. PCAT density was higher in transplant patients with CAV (n = 40; -73.0 HU [SD 9.3]) than without CAV (n = 86; -77.9 HU [SD 8.2]), and controls (n = 12; -86.2 HU [SD 5.4]), p < 0.01 for both. Unlike patients with atherosclerotic coronary artery disease (n = 32), CAV lesions were predominantly non-calcified, comprised of mostly fibrous or fibrofatty tissue. V/M was lower in patients with CAV than without (32.4 mm3/g [SD 9.7] vs. 41.4 mm3/g [SD 12.3], p < 0.0001). PCAT density and V/M improved the ability to predict CAV from AUC 0.75 to 0.85 when added to donor age and donor hypertension status (p < 0.0001). PCAT density above -66 HU was associated with a greater incidence of all-cause mortality (OR 18.0 [95%CI 3.25-99.6], p < 0.01) and the composite endpoint of death, CAV progression, acute rejection, and coronary revascularization (OR 7.47 [95%CI 1.8-31.6], p = 0.01) over 5.3 (SD 2.1) years.

CONCLUSIONS

Heart transplant patients with CAV have higher PCAT density and lower V/M than those without. Increased PCAT density is associated with adverse clinical outcomes. These CCTA metrics could be useful for diagnosis and monitoring of CAV severity.

Peri-Carotid Adipose Tissue and Atherosclerosis at Carotid Bifurcation

Vulnerable carotid plaques are responsible for 20% of the ischemic strokes. The identification of these asymptomatic carotid plaques that will become symptomatic is essential but remains unclear. Our main goal was to investigate whether the amount of the peri-carotid adipose tissue, estimated by the extra-media thickness (EMT), is associated with the atherosclerotic characteristics at the carotid bifurcation in patients with PAD. An observational, prospective, single-center, longitudinal study was conducted. Overall, 177 patients were subjected to carotid Doppler ultrasound at the study admission. The following data were collected: EMT, intima-media thickness (IMT), the presence of carotid plaques, the area of the highest plaque, the presence of "acute culprit" carotid stenosis, and the grade of internal carotid stenosis. "Acute culprit" carotid stenosis was defined as a significant atherosclerotic plaque that leads to a neurologic event within 15 days. From each carotid bifurcation, a right and a left EMT were determined. We analyzed both the mean EMTs (calculated as the mean between the right and the left EMT) and the EMT ipsilateral to the carotid bifurcation. The presence of carotid plaques was associated with a higher mean EMT [Median = 1.14; IQR = 0.66 versus Median = 0.97; IQR = 0.40; p = 0.001]. A positive correlation was found between the mean EMT and IMT (right: ρ = 0.20; p = 0.010; left: ρ = 0.21; p = 0.007) and between the mean EMT and the area of the largest carotid plaque (right: ρ = 0.17; p = 0.036; left: ρ = 0.22; p = 0.004). Left carotid stenosis ≥ 70% was associated with higher ipsilateral EMT [Median = 1.56; IQR = 0.70 versus Median = 0.94; IQR = 0.42; p = 0.009]. Patients with "acute culprit" carotid stenosis had a higher ipsilateral EMT [left ipsilateral EMT: Median = 1.46; IQR = 0.63; "non-acute": Median = 0.94; IQR = 0.43; p = 0.009; right ipsilateral EMT: Median = 2.25; IQR = 0.62; "non-acute": Median = 1.00; IQR = 0.51; p = 0.015]. This difference was not found in the contra-lateral EMT. Six months after the neurologic event, EMT ipsilateral to an "acute culprit" carotid stenosis decreased (p = 0.036). The amount of peri-carotid adipose tissue, estimated with EMT, was associated with atherosclerosis at the carotid arteries. The mean EMT was associated with the features of chronic atherosclerosis lesions: the presence of carotid plaques, IMT, and the area of the highest plaque. Ipsilateral EMT was linked with "acute culprit" atherosclerotic plaque.

Pericoronary Adipose Tissue Density, Inflammation, and Subclinical Coronary Artery Disease Among People With HIV in the REPRIEVE Cohort

BACKGROUND

Pericoronary adipose tissue (PCAT) may influence plaque development through inflammatory mechanisms. We assessed PCAT density, as a measure of pericoronary inflammation, in relationship to coronary plaque among people with human immunodeficiency virus (HIV [PWH]) and to a matched control population.

METHODS

In this baseline analysis of 727 participants of the Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) Mechanistic Substudy, we related computed tomography-derived PCAT density to presence and extent (Leaman score) of coronary artery disease (CAD), noncalcified plaque, coronary artery calcium (CAC), and vulnerable plaque features using multivariable logistic regression analyses. We further compared the PCAT density between PWH and age, sex, body mass index, CAC score, and statin use-matched controls from the community-based Framingham Heart Study (N = 464), adjusting for relevant clinical covariates.

RESULTS

Among 727 REPRIEVE participants (age 50.8 ± 5.8 years; 83.6% [608/727] male), PCAT density was higher in those with (vs without) coronary plaque, noncalcified plaque, CAC >0, vulnerable plaque, and high CAD burden (Leaman score >5) (P < .001 for each comparison). PCAT density related to prevalent coronary plaque (adjusted odds ratio [per 10 HU]: 1.44; 95% confidence interval, 1.22-1.70; P < .001), adjusted for clinical cardiovascular risk factors, body mass index, and systemic immune/inflammatory biomarkers. Similarly, PCAT density related to CAC >0, noncalcified plaque, vulnerable plaque, and Leaman score >5 (all P ≤ .002). PCAT density was greater among REPRIEVE participants versus Framingham Heart Study (-88.2 ± 0.5 HU versus -90.6 ± 0.4 HU; P < .001).

CONCLUSIONS

Among PWH in REPRIEVE, a large primary cardiovascular disease prevention cohort, increased PCAT density independently associated with prevalence and severity of coronary plaque, linking increased coronary inflammation to CAD in PWH.

[Coronary CT angiography and coronary atherosclerosis : Where do we stand today?]

Cardiac computed tomography (CT) has made substantial progress in recent years. The main field of application is CT coronary angiography for visualization of the coronary arteries and for the detection and exclusion of coronary artery stenosis. This has been included in international guidelines for the management of stable coronary artery disease or chronic coronary syndrome as well as for the diagnostic work-up of patients with acute chest pain; however, it must be taken into account that the diagnostic validity is only sufficiently high when the image quality is good and therefore alternative diagnostic procedures should be included in patients where an unrestricted good image quality is not to be expected. The fact that CT angiography enables the detection not only of coronary stenosis but also of nonobstructive atherosclerotic plaque is interesting for the estimation of the risk of atherosclerotic events. It is practically certain that in the absence of detectable atherosclerotic plaque in CT angiography, statin treatment does not lower the risk of atherosclerotic events. To what extent CT is suitable to provide indications for statin treatment and the threshold for which the presence of nonobstructive plaque should prompt initiation of statin treatment are currently the subject of intensive research.

Computed tomography measured epicardial adipose tissue and psoas muscle attenuation: new biomarkers to predict major adverse cardiac events (MACE) and mortality in patients with heart disease and critically ill patients. Part I: Epicardial adipose tissue

Over the last two decades, the potential role of epicardial adipocyte tissue (EAT) as a marker for major adverse cardiovascular events has been extensively studied. Unlike other visceral adipocyte tissues (VAT), EAT is not separated from the adjacent myocardium by a fascial layer and shares the same microcirculation with the myocardium. Adipocytokines, secreted by EAT, interact directly with the myocardium through paracrine and vasocrine pathways. The role of the Randle cycle, linking VAT accumulation to insulin resistance, and the relevance of blood flow and mitochondrial function of VAT, are briefly discussed. The three available imaging modalities for the assessment of EAT are discussed. The advantages of echocardiography, cardiac CT, and cardiac magnetic resonance (CMR) are compared. The last section summarises the current stage of knowledge on EAT as a clinical marker for major adverse cardiovascular events (MACE). The association between EAT volume and coronary artery disease (CAD) has robustly been validated. There is growing evidence that EAT volume is associated with computed tomography coronary angiography (CTCA) assessed high-risk plaque features. The EAT CT attenuation coefficient predicts coronary events. Many studies have established EAT volume as a predictor of atrial fibrillation after cardiac surgery. Moreover, EAT thickness has been independently associated with severe aortic stenosis and mitral annular calcification. Studies have demonstrated that EAT volume is associated with heart failure. Finally, we discuss the potential role of EAT in critically ill patients admitted to the intensive care unit. In conclusion, EAT seems to be a promising new biomarker to predict MACE.