Relationship between coronary calcium score and high-risk plaque/significant stenosis

AIMTo investigate the relationship between coronary calcium score (CCS) and vulnerable plaque/significant stenosis using coronary computed tomographic angiography (CCTA).METHODSCCTA was performed in 651 patients and these patients were divided into the four groups (CCS 0, 1-100, 101-400 and > 400). We studied the incidence of high-risk plaque, including positive remodeling, low attenuation plaque, spotty calcification, and napkin-ring sign, and significant stenosis in each group.RESULTSHigh-risk plaque was found in 1.3%, 10.1%, 13.3% and 13.4% of patients with CCS 0, 1-100, 101-400 and > 400, respectively (P < 0.001). The difference was only significant for patients with zero CCS. The incidence of significant stenosis was 0.6%, 7.6%, 13.3% and 26.9% for each patient group, respectively (P < 0.001), which represented a significant stepwise increase as CCS increased. The combined incidence of high-risk plaque and significant stenosis was 1.9%, 17.7%, 26.9% and 40.3% in each patient group, respectively (P < 0.001), again representing a significant stepwise increase with CCS. The rate of major coronary event was 0%, 4.0%, 7.9% and 17.2% in each patient group, respectively (P < 0.001), another significant stepwise increase as CCS increased.CONCLUSIONStepwise increased risk of coronary events associated with increasing CCS is caused by increasing incidence of significant stenosis, while that of high-risk plaque remains the same.     

A computed tomography-based coronary lesion score to predict acute coronary syndrome among patients with acute chest pain and significant coronary stenosis on coronary computed tomographic angiogram

We tested the hypothesis that morphologic lesion assessment helps detect acute coronary syndrome (ACS) during index hospitalization in patients with acute chest pain and significant stenosis on coronary computed tomographic angiogram (CTA). Patients who presented to an emergency department with chest pain but no objective signs of myocardial ischemia (nondiagnostic electrocardiogram and negative initial biomarkers) underwent CT angiography. CTA was analyzed for degree and length of stenosis, plaque area and volume, remodeling index, CT attenuation of plaque, and spotty calcium in all patients with significant stenosis (>50% in diameter) on CTA. ACS during index hospitalization was determined by a panel of 2 physicians blinded to results of CT angiography. For lesion characteristics associated with ACS, we determined cutpoints optimized for diagnostic accuracy and created lesion scores. For each score, we determined the odds ratio (OR) and discriminatory capacity for the prediction of ACS. Of the overall population of 368 patients, 34 had significant stenosis and 21 of those had ACS. Scores A (remodeling index plus spotty calcium: OR 3.5, 95% confidence interval [CI] 1.2 to 10.1, area under curve [AUC] 0.734), B (remodeling index plus spotty calcium plus stenosis length: OR 4.6, 95% CI 1.6 to 13.7, AUC 0.824), and C (remodeling index plus spotty calcium plus stenosis length plus plaque volume <90 HU: OR 3.4, 95% CI 1.5 to 7.9, AUC 0.833) were significantly associated with ACS. In conclusion, in patients presenting with acute chest pain and stenosis on coronary CTA, a CT-based score incorporating morphologic characteristics of coronary lesions had a good discriminatory value for detection of ACS during index hospitalization.     

Impact of coronary calcium score on diagnostic accuracy for the detection of significant coronary stenosis with multislice computed tomography angiography

One hundred twenty patients in sinus rhythm with suspected coronary artery disease who underwent multislice computed tomography of the heart and conventional coronary angiography were retrospectively selected. The population was divided into 2 groups depending on their calcium score (CS) (e.g., low CS and high CS). The diagnostic accuracy of multislice computed tomographic scans for detecting significant lesions (>50% lumen reduction) in both groups was compared with quantitative coronary angiography. The sensitivity and specificity of multislice computed tomography were 90% and 92%, and 97% and 91% for low and high CS groups, respectively.     

Presence and severity of noncalcified coronary plaque on 64-slice computed tomographic coronary angiography in patients with zero and low coronary artery calcium

How well absence of coronary artery calcium (CAC) predicts the absence of noncalcified coronary artery plaque (NCAP) has not been elucidated. We conducted a cross-sectional study of 554 outpatients to quantify NCAP prevalence as a function of CAC score. All patients underwent CAC scoring followed by 64-slice computed tomographic coronary angiography. Patients were categorized as having 0 CAC (416 patients) or low CAC (138 patients; men with CAC scores from 1 to 50 and women with scores from 1 to 10). Prevalence of detectable NCAP was 6.5% in patients with 0 CAC and 65.2% in those with low CAC. Compared with patients with 0 CAC, those with low CAC had markedly increased rates of NCAP occluding <50% of the arterial lumen (56.5% vs 6.0%, p <0.001) and > or =50% of the arterial lumen (8.7% vs 0.5%, p <0.001). In conclusion, in outpatients with a low to intermediate risk presentation and no known coronary artery disease, absence of CAC predicts low prevalence of any NCAP and very low prevalence of significantly occlusive NCAP. Low but detectable CAC scores are significantly less reliable in predicting plaque burden due to their association with high overall NCAP prevalence and nearly a 10% rate of significantly occlusive NCAP.     

Aortic root calcification and cardiac risk factors in patients with coronary calcium score greater than zero using multidetector computed tomography

BackgroundVascular calcification is a marker of atherosclerotic burden and is associated with increased risk of cardiac events. The aim of this study was to investigate the relationship between clinical cardiac risk factors and aortic root calcification (ARC) in patients with a coronary calcium score (CCS) > 0, as assessed by multidetector computed tomography (MDCT).MethodsBetween January and December 2013, 196 consecutive Iraqi patients who underwent MDCT for assessment of coronary disease were recruited. Of these, 69 patients with a CCS > 0 were enrolled in the study. For analytical purposes, patients were divided into two groups by ARC score: patients with ARC > 0 (ARC group, n = 32) and those with ARC = 0 (non-ARC group, n = 37).ResultsThe overall prevalence of ARC was 46%. Mean ARC was 174 ± 28.5 (range, 10–500). A significant correlation was observed between ARC and male sex (r = 0.380, P = 0.032) and between ARC and age ≥65 years (r = 0.353, P = 0.047). These correlations persisted even after multivariate adjustment for other cardiac risk factors. There were no significant correlations between ARC and other cardiac risk factors, and the only significant between-group difference in the distribution of cardiac risk factors was in patient age.ConclusionARC was significantly correlated with older age and male sex in patients with CCS > 0.     

冠状动脉0钙化积分人群非钙化性斑块的发生率及其危险因素分析简

目的 利用计算机断层扫描（computerized tomography,CT）冠状动脉成像,研究冠状动脉0钙化积分人群非钙化性斑块的发生率及管腔狭窄程度,并分析其相关危险因素.方法 对968例冠状动脉0钙化积分患者的影像学资料和临床资料进行回顾性分析,所有患者均行64层螺旋CT冠状动脉钙化积分扫描及CT冠状动脉成像检查;采用单因素分析和Logistic回归分析冠状动脉非钙化性斑块形成的相关危险因素.结果 968例患者中,203例（21.0％）检出非钙化性斑块,斑块导致轻度狭窄124例（61.1％）、中度狭窄53例（26.1％）、重度狭窄26例（12.8％）.Logistic回归分析显示原发性高血压（高血压）（OR=3.994,P=0.010）、男性（OR=2.663,P=0.000）、吸烟史（OR=1.376,P=0.001）、甘油三酯增高（OR=3.536,P=0.000）、高密度脂蛋白胆固醇降低（OR=0.653,P=0.008）为冠状动脉非钙化性斑块形成的危险因素.糖尿病史、血清甘油三酯和高密度脂蛋白胆固醇浓度与斑块导致的管腔狭窄程度有关.结论 冠状动脉0钙化积分人群中有相当比例的人存在非钙化性斑块,高血压、高脂血症为非钙化性斑块形成的两大独立危险因素.     

Prevalence and extent of obstructive coronary artery disease in patients with zero or low calcium score undergoing 64-slice cardiac multidetector computed tomography for evaluation of a chest pain syndrome

We examined the extent of coronary artery disease (CAD) on 64-slice contrast-enhanced multidetector computed tomography in patients who underwent investigation of a chest pain syndrome who had a zero or low coronary calcium score (CS). In 668 consecutive patients with chest pain syndromes (39% with acute presentation, 61% with long-term presentation) who underwent cardiac multidetector computed tomography, we assessed prevalence and severity of coronary stenoses (>or=1 coronary artery stenosis with >or=50% luminal narrowing) in 231 patients (54 +/- 12 years of age, 45% women) with a 0 (n = 125) or low (n = 106) coronary CS. Obstructive (>or=50% lesion) CAD was present in 27 of 231 patients, in 9 of 125 patients (7%) with a 0 CS, in 18 of 106 (17%) with a low CS (1 to 100), and in 14 of 90 patients (16%) with an acute presentation and 13 of 141 patients (9%) with a long-term presentation (p = NS). All patients in the 0 CS group had single-vessel disease, and 9 (50%) with low CS had multivessel disease, with left main involvement in 1. Of the 27 patients with obstructive CAD on multidetector computed tomography, invasive coronary angiography confirmed these findings in 21 of 23 patients (positive predictive value 91%), and 16 (76%) of them (6.9% of the 0 CS and low CS groups) underwent a myocardial revascularization procedure after invasive coronary angiographic concordance. In conclusion, despite the high known negative predictive value of CS for coronary events, a low and even 0 CS does not exclude clinically important obstructive CAD in patients undergoing investigation of an acute or long-term chest pain syndrome. Contrast-enhanced multidetector computed tomography should be the noninvasive computed tomographic test of choice when possible in these patients.     

颈动脉斑块性质和管腔狭窄与年龄的相关性研究

目的探讨年龄与颈动脉管腔狭窄及斑块性质的关系。方法随机对照研究,选择2012年1月~2014年1月在青岛市市立医院行颈动脉超声检查的患者165例,根据临床及影像学表现分为缺血性脑卒中组100例和非脑卒中组65例,分析缺血性脑卒中发病的危险因素。其次,根据年龄分为中青年组(年龄≤59岁)36例,老年组(60~79岁)98例,高龄组(年龄≥80岁)31例,对3组患者的颈动脉狭窄程度、斑块性质进行统计分析。结果缺血性脑卒中组年龄、高血压、易损斑块及管腔重度狭窄比例明显高于非脑卒中组[(70.6±11.2)岁vs(65.1±12.8)岁,P=0.004;79.0%vs 60.0%,P=0.008;40.0%vs 24.6%,P=0.041;20.0%vs 6.2%,P=0.014]。高龄组管腔重度狭窄比例明显高于中青年组及老年组(54.8%vs 2.8%和6.1%,P0.01)。与中青年组比较,老年组和高龄组稳定斑块及易损斑块检出率明显升高,差异有统计学意义(P0.01)。多因素logistic回归分析显示,年龄是缺血性脑卒中的危险因素(OR=1.039,95%CI:1.011~1.068,P=0.005)。年龄是颈动脉重度狭窄及易损斑块的危险因素(OR=1.225,95%CI:1.125~1.335,P=0.000;OR=1.035,95%CI:1.005~1.065,P=0.023)。结论年龄增长是缺血性脑卒中的危险因素,缺血性脑卒中患者比非脑卒中患者易损斑块多且管腔重度狭窄比例大。年龄≥60岁患者颈动脉易损斑块多于年龄≤59岁患者,年龄≥80岁患者管腔重度狭窄比例最高,发生缺血性脑卒中危险性可能更大。     

Comparison of prognostic usefulness (three years) of computed tomographic angiography versus 64-slice computed tomographic calcium scanner in subjects without significant coronary artery disease

Coronary computerized tomographic angiography (CTA) has been used as a noninvasive method for ruling out high-grade stenoses. Even in the absence of such stenoses, analysis of coronary atherosclerosis may provide for important prognostic information, and this may be superior to exclusive coronary artery calcium scoring. We tested this hypothesis in patients undergoing CTA for clinical indications who had no stenoses requiring revascularization. From December 2004 to December 2006, 706 consecutive patients who underwent CTA but had no high-grade stenoses were included (58% men, mean age 59 ± 11 years). CTA and coronary artery calcium scoring (Agatston method) were performed using a 64-slice CT scanner with a gantry rotation time of 330 ms. CT angiograms were categorized as completely normal (group 1), showing minor plaque (group 2), or showing intermediate stenoses (group 3). Follow-up information was obtained in 670 patients (95%) over a mean of 3.2 years. There were 31 major adverse events (5%), namely 9 deaths (all noncoronary), 2 myocardial infarctions, 5 strokes, 13 coronary revascularization procedures (percutaneous or surgical > 6 months after CTA), and 2 peripheral percutaneous interventions. Coronary status as defined by CTA was predictive of major events after adjustment for age and gender. In group 1, the probability of event-free survival at 3 years was 100%; in group 2, it was 96%; and in group 3, it was 91%. Compared to group 1, the risk in group 2 was increased 2.3-fold, and in group 3, it was increased 5.6-fold after adjusting for age and gender. However, after addition of the coronary artery calcium score to the regression analysis, CT angiographic status no longer appeared to be predictive. In conclusion, the risk of a major adverse cardiovascular event or death increased in a graded manner with degree of coronary atherosclerosis as defined by CTA even in the absence of high-grade coronary stenoses. However, in the absence of high-grade stenoses, we were unable to demonstrate a superior prognostic value of CTA compared to coronary artery calcium.     

Usefulness of coronary computed tomographic angiography to assess suitability for revascularization in patients with significant coronary artery disease and angina pectoris

Coronary computed tomographic angiography (CTA) accurately excludes the presence of coronary stenoses in selected patient populations. However, it remains unclear whether coronary CTA has the potential to replace invasive coronary angiography as a tool to assess a patient's suitability for revascularization as determined by the characterization of lesion morphology in patients with significant coronary artery disease. Coronary CTA (64-slice computed tomography) was performed before invasive coronary angiography in 29 patients. We evaluated the accuracy of CTA for the detection of complex lesion morphology, including the presence of severe calcium, total occlusions, and ostial or bifurcation location, and compared the results with those of invasive angiography. On CTA, 10 of 69 lesions (15%) were not evaluable for any feature of complex lesion morphology. Of the evaluable lesions, CTA detected >or=1 feature of complexity in 58% of lesions, corresponding to a sensitivity of 88% (23 of 26) and a specificity of 83% (24 of 29). For those single features, the sensitivity of CTA was 100% for the presence of severe calcium, 93% for total occlusions, and 60% and 80% for the detection of ostial and bifurcation lesions, respectively. The specificity was high for total occlusions (97%), ostial lesions (97%), and bifurcations (100%). It was moderate (85%) for severe calcium. Severe calcium precluded the evaluation of other features of complex lesion morphology in 6 lesions (11%). In conclusion, invasive selective coronary angiography remains the cornerstone to assess a patient's suitability for revascularization given the high proportion of unevaluable segments and segments with severe calcium that precluded adequate revascularization planning on CTA.     

Impact of clinical presentation and pretest likelihood on the relation between calcium score and computed tomographic coronary angiography

The purpose of the present study was to assess the impact of clinical presentation and pretest likelihood on the relation between coronary calcium score (CCS) and computed tomographic coronary angiography (CTA) to determine the role of CCS as a gatekeeper to CTA in patients presenting with chest pain. In 576 patients with suspected coronary artery disease (CAD), CCS and CTA were performed. CCS was categorized as 0, 1 to 400, and >400. On CT angiogram the presence of significant CAD (≥50% luminal narrowing) was determined. Significant CAD was observed in 14 of 242 patients (5.8%) with CCS 0, in 94 of 260 patients (36.2%) with CCS 1 to 400, and in 60 of 74 patients (81.1%) with CCS >400. In patients with CCS 0, prevalence of significant CAD increased from 3.9% to 4.1% and 14.3% in nonanginal, atypical, and typical chest pain, respectively, and from 3.4% to 3.9% and 27.3% with a low, intermediate, and high pretest likelihood, respectively. In patients with CCS 1 to 400, prevalence of significant CAD increased from 27.4% to 34.7% and 51.7% in nonanginal, atypical, and typical chest pain, respectively, and from 15.4% to 35.6% and 50% in low, intermediate, and high pretest likelihood, respectively. In patients with CCS >400, prevalence of significant CAD on CT angiogram remained high (>72%) regardless of clinical presentation and pretest likelihood. In conclusion, the relation between CCS and CTA is influenced by clinical presentation and pretest likelihood. These factors should be taken into account when using CCS as a gatekeeper for CTA.     

Impact of epicardial fat volume on coronary artery disease in symptomatic patients with a zero calcium score

Background

This study sought to evaluate the prevalence of coronary artery disease (CAD) and the impact of epicardial fat volume (EFV) on CAD in symptomatic patients with a zero calcium score (CS) using multislice computed tomography (MSCT).

Methods

In this study, 1308 consecutive symptomatic patients who underwent 64-slice MSCT with a zero CS were evaluated. EFV was quantified with CS data sets. Presence of an obstructive plaque (diameter stenosis > 50%) and a CT-derived vulnerable plaque, which was defined as a plaque with remodeling index > 1.10 and mean CT density value < 30 HU, was assessed with a CT coronary angiography.

Results

Obstructive plaques were detected in 86 patients (7%) and CT-derived vulnerable plaques in 63 (5%). EFV was larger in patients with obstructive plaques than no plaque (124.3 ± 43.2 cm³ vs. 95.1 ± 40.3 cm³; p < 0.01). Patients with CT-derived vulnerable plaques had a greater amount of EFV than no plaque (133.0 ± 40.2 cm³ vs. 95.1 ± 40.3 cm³; p < 0.01). Multivariate analysis revealed EFV as a predictor of the presence of an obstructive and a CT-derived vulnerable plaque (per 10 cm³; Odds ratio (OR) 1.10; 95% confidence interval (CI), 1.04-1.16; p < 0.01 and OR 1.19; 95% CI, 1.12-1.27; p < 0.01). The combination of EFV and Framingham risk score (FRS) resulted in an area under the receiver-operating characteristic curve for prediction of obstructive and CT-derived vulnerable plaque of 0.75 and 0.75, which was significantly higher than 0.68 and 0.64 for FRS alone (p = 0.02 and p < 0.01).

Conclusions

A zero CS doesn't exclude CAD and EFV can be a useful marker of CAD in symptomatic zero CS patients.     

Comprehensive coronary risk determination in primary prevention: an imaging and clinical based definition combining computed tomographic coronary artery calcium score and national cholesterol education program risk score

Cardiovascular disease (CVD) is the leading cause of mortality and a major cause of morbidity. Coronary heart disease (CHD) accounts for nearly half of all CVD deaths. Currently estimation of risk in primary prevention is based on the Framingham risk equations, which inputs traditional risk factors and is helpful in predicting the development of CHD in asymptomatic individuals. However many individuals suffer events in the absence of established risk factors for atherosclerosis and broad based population risk estimations may have little precision when applied to a given individual. To meet the challenge of CHD risk assessment, several tools have been developed to identify atherosclerotic disease in its preclinical stages. This paper aims to incorporate information from coronary artery calcification (CAC) scoring from a computed tomographic "heartscan" (using Electron Beam Tomography (EBT) as the validated prototype) along with current Framingham risk profiling in order to refine risk on an absolute scale by combining imaging and clinical data to affect a more comprehensive calculation of absolute risk in a given individual. For CAC scores above the 75th percentile but <90th percentile, 10 years is added to chronological age, and for CAC scores above the 90th percentile, 20 years is added to current chronological age. Among those in whom a positive CAC score is the norm such as older individuals (men> or =55 years, women> or =65 years) a CAC = 0 will result in an age point score corresponding to the age-group whose median CAC score is zero i.e., 40-44 years for men and 55-59 years for women. The utilization of CAC scores allows the inclusion of sub-clinical disease definition into the context of modifiable risk factors as well as identifies high-risk individuals requiring aggressive treatment.     

320排CT仿真内镜在冠状动脉支架术后应用价值研究

冠状动脉支架术是治疗冠状动脉狭窄的重要手段之一,但术后仍有10%～20%的患者可能出现支架内再狭窄,所以早期准确地评价支架术后再狭窄问题正日益受到重视。目前,冠状动脉造影(CAG)仍是诊断支架内再狭窄的金标准,但缺点是有创伤,且不能提供支架内血管壁病变的详细信息。普通CT机观察血管内支架的通畅情况容易受支架的材     

Prevalence of microvascular disease in patients with significant coronary artery disease

Coronary flow velocity reserve (CFVR) measurement using intracoronary Doppler techniques has been increasing accepted for the assessment of physiological significance of epicardial stenosis and the functional changes after coronary interventions. However, large discrepancy exists concerning the acute changes of CFVR immediately after intervention. The purpose of this study was to investigate the prevalence of microvascular dysfunction in patients with significant coronary artery disease. Intracoronary Doppler flow measurements were performed in a total of 212 patients who underwent coronary interventions because of significant epicardial stenosis using 0.014" Doppler flow wire (Cardiometrics, Inc, Mountain View, CA). Intracoronary bolus injection of adenosine (12 micrograms for the right coronary and 18 micrograms for the left coronary arteries) was used to induce hyperemic reaction. CFVR was registered as the ratio of average peak velocity during hyperemia (hAPV) to at baseline (bAPV). Successful coronary interventions either by percutaneous transluminal coronary balloon angioplasty (PTCA) or by stenting could significantly improve the CFVR. In 80 patients with PTCA, the bAPV elevated from 16.6 +/- 2.1 cm/s to 20.6 +/- 13.4 cm/s and hAPV from 30.1 +/- 15.9 cm/s to 45.2 +/- 17.7 cm/s (both p < 0.001) with PTCA and the CFVR increased from 1.94 +/- 0.78 to 2.58 +/- 0.87 correspondingly (p < 0.001). Significant elevation of coronary flow parameters were also found in 132 patients with subsequent stent implantation (bAPV from 15.3 +/- 6.7 cm/s to 18.7 +/- 9.1 cm/s, hAPV from 28.7 +/- 14.4 cm/s to 44.3 +/- 17.7 cm/s and CFVR from 1.90 +/- 0.70 to 2.59 +/- 0.87, all p < 0.001). Reduction of CFVR (< 3.0) after intervention still existed in 46 (61.3%) of 80 patients after PTCA and 88 (66.7%) of 132 patients after stenting. Moreover, CFVR < 3.0 were found in 50 (45.9%) of 109 reference vessels in patients with single vessel disease. Significant improvement of coronary flow velocity and coronary flow velocity reserve could be obtained after successful angioplasty. However, microvascualr dysfunction existed in a large proportion of patients either in normal reference vessels or in target vessels after interventions.