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Prognostic Value and Therapeutic Perspectives of Coronary CT Angiography: A Literature Review.

ABSTRACT: Coronary stenosis severity is both a powerful and a still debated predictor of prognosis in coronary artery disease. Coronary computed tomographic angiography (CCTA) has emerged as a noninvasive technique that enables anatomic visualization of coronary artery disease (CAD). CCTA with newer applications, plaque characterization and physiologic/functional evaluation, allows a comprehensive diagnostic and prognostic assessment of otherwise low-intermediate subjects for primary prevention. CCTA measures the overall plaque burden, differentiates plaque subtypes, and identifies high-risk plaque with good reproducibility. Research in this field may also advance towards an era of personalized risk prediction and individualized medical therapy. It has been demonstrated that statins may delay plaque progression and change some plaque features. The potential effects on plaque modifications induced by other medical therapies have also been investigated. Although it is not currently possible to recommend routinely serial scans to monitor the therapeutic efficacy of medical interventions, the plaque modulation, as a part of risk modification, appears a feasible strategy. In this review we summarize the current evidence regarding vulnerable plaque and effects of lipid lowering therapy on morphological features of CAD. We also discuss the potential ability of CCTA to characterize coronary atherosclerosis, stratify prognosis of asymptomatic subjects, and guide medical therapy.

SUBMITTER: Carita P

PROVIDER: S-EPMC6165606 | biostudies-other | 2018

REPOSITORIES: biostudies-other

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Prognostic Value and Therapeutic Perspectives of Coronary CT Angiography: A Literature Review.

Carità Patrizia P Guaricci Andrea Igoren AI Muscogiuri Giuseppe G Carrabba Nazario N Pontone Gianluca G

BioMed research international 20180916

Coronary stenosis severity is both a powerful and a still debated predictor of prognosis in coronary artery disease. Coronary computed tomographic angiography (CCTA) has emerged as a noninvasive technique that enables anatomic visualization of coronary artery disease (CAD). CCTA with newer applications, plaque characterization and physiologic/functional evaluation, allows a comprehensive diagnostic and prognostic assessment of otherwise low-intermediate subjects for primary prevention. CCTA meas ...[more]

PMID: 30306089

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Project description:BackgroundCoronary magnetic resonance angiography (CMRA) allows non-ionizing visualization of luminal narrowing in coronary artery disease (CAD). Although a prior study showed the usefulness of CMRA for risk stratification in short-term follow-up, the long-term prognostic value of CMRA remains unclear. The purpose of this study was to evaluate the long-term prognostic value of CMRA.MethodsA total of 506 patients without history of myocardial infarction or prior coronary artery revascularization underwent free-breathing whole-heart CMRA between 2009 and 2015. Images were acquired using a 1.5 T or 3 T scanner and visually evaluated as the consensus decisions of two observers. Obstructive CAD on CMRA was defined as luminal narrowing of ≥ 50% in at least one coronary artery. Major adverse cardiac events (MACE) comprised cardiac death, nonfatal myocardial infarction, and unstable angina.ResultsObstructive CAD on CMRA was observed in 214 patients (42%). During follow-up (median, 5.6 years), 31 MACE occurred. Kaplan-Meier curve analysis revealed a significant difference in event-free survival between patients with and without obstructive CAD for MACE (log-rank, p = 0.003) and cardiac death (p = 0.012). Annualized event rates for MACE in patients with no obstructive CAD, 1-vessel disease, 2-vessel disease, and left-main or 3-vessel disease were 0.6%, 1.5%, 2.3%, and 3.6%, respectively (log-rank, p = 0.003). Cox proportional hazard regression analysis showed that, among obstructive CAD on CMRA and clinical risk factors (age, sex, hypertension, diabetes, dyslipidemia, smoking, and family history of CAD), obstructive CAD and diabetes were significant predictors of MACE (hazard ratios, 2.9 [p = 0.005] and 2.2 [p = 0.034], respectively). In multivariate analysis, obstructive CAD remained an independent predictor (adjusted hazard ratio, 2.6 [p = 0.010]) after adjusting for diabetes. Addition of obstructive CAD to clinical risk factors significantly increased the global chi-square result from 8.3 to 13.8 (p = 0.022).ConclusionsIn long-term follow-up, free breathing whole heart CMRA allows non-invasive risk stratification for MACE and cardiac death and provides incremental prognostic value over conventional risk factors in patients without a history of myocardial infarction or prior coronary artery revascularization. The presence and severity of obstructive CAD detected by CMRA were associated with worse prognosis. Importantly, patients without obstructive CAD on CMRA displayed favorable prognosis.

Project description:PurposeTo determine the impact of low tube voltage coronary CT angiography on detection of subclinical atherosclerosis.Materials and methodsRetrospective sampling of an emergency department coronary CT angiography registry was performed. All patients in the registry underwent a noncontrast coronary artery calcium (CAC) scoring scan at 120 kV before coronary CT angiography. The study sample (n = 264) constituted patients with subclinical atherosclerosis (Coronary Artery Disease Reporting and Data System™ [CAD-RADS] 1 or 2) randomly mixed one-to-one with patients without atherosclerosis (CAD-RADS 0). The patients with coronary CT angiography performed at 70-90 kV were considered the low tube voltage group (n = 159) and patients with coronary CT angiography performed at 100-120 kV were considered the standard tube voltage group (n = 105). The number of coronary plaques and overall CAD-RADS classification (per patient) were evaluated twice: initially, by reading coronary CT angiography alone, and then, by coronary CT angiography in combination with a CAC scan. Considering the combined reading (CT angiography plus CAC scan) as the reference standard, the performance of coronary CT angiography alone was assessed for plaque detection and appropriate CAD-RADS (per patient) classification. The comparisons were made between the low tube voltage and standard tube voltage groups by using a Fisher exact test and χ2 test for proportions and a Mann-Whitney test and Kruskal-Wallis test for means.ResultsIn total, 455 plaques were identified in 118 patients (70 of 159 patients in the low tube voltage group; 48 of 105 in the standard tube voltage group). When reading coronary CT angiographic images alone, 97 of 455 (21%) plaques were missed that led to an incorrect CAD-RADS classification in 16 of 264 (6%) studies (interpreted as CAD-RADS 0 instead of CAD-RADS 1 or 2). Missed plaques were significantly more frequent in the low tube voltage group versus the standard tube voltage group (41% [85 of 206] vs 5% [12 of 249], respectively; P < .001). Incorrect CAD-RADS classification was also seen more commonly in the low tube voltage group (8.8% [14 of 159] vs 2% [two of 105]; P = .01), typically at low plaque burden (median CAC score, 1; range, 1-4). Calcified plaques that appeared isodense to luminal contrast material attenuation were seen more frequently in the low tube voltage group compared with the standard tube voltage group (20% [32 of 159] vs 7.6% [eight of 105], respectively; P = .005).ConclusionCoronary artery plaques may be missed at low tube voltage coronary CT angiographic examination performed without a concomitant CAC scan.© RSNA, 2019Supplemental material is available for this article.See also the commentary by Truong in this issue.

Project description:Background: Angiography-derived index of microcirculatory resistance (angio-IMR) is an emerging pressure-wire-free index to assess coronary microvascular function, but its diagnostic and prognostic value remains to be elucidated. Methods and Results: The study population consisted of three independent cohorts. The internal diagnostic cohort enrolled 53 patients with available hyperemic microcirculatory resistance (HMR) calculated from myocardial blood flow and pressure. The external diagnostic cohort included 35 ischemia and no obstructive coronary artery disease (INOCA) patients and 45 controls. The prognostic cohort included 138 coronary artery disease (CAD) patients who received PCI. Angio-IMR was calculated after the estimation of angiography-derived fractional flow reserve (angio-FFR) using the equation of angio-IMR = estimated hyperemic Pa × angio-FFR × [vessel length/(K × Vdiastole)]. The primary outcome was a composite of cardiac death or readmission due to heart failure at 28 months after index procedure. Angio-IMR demonstrated a moderate correlation with HMR (R = 0.74, p < 0.001) and its diagnostic accuracy, sensitivity, specificity, and area under the curve to diagnose INOCA were 79.8, 83.1, 78.0, and 0.84, respectively, with a best cut-off of 25.1. Among prognostic cohort, patients with angio-IMR ≥25.1 showed a significantly higher risk of cardiac death or readmission due to heart failure than those with an angio-IMR <25.1 (18.6 vs. 5.4%, adjusted HR 9.66, 95% CI 2.04-45.65, p = 0.004). Angio-IMR ≥25.1 was an independent predictor for cardiac death or readmission due to heart failure (HR 11.15, 95% CI 1.76-70.42, p = 0.010). Conclusions: Angio-IMR showed a moderate correlation with HMR and high accuracy to predict microcirculatory dysfunction. Angio-IMR measured after PCI predicts the risk of cardiac death or readmission due to heart failure in patients with CAD. Clinical Trial Registration: Diagnostic and Prognostic Value of Angiography-derived IMR (CHART-MiCro), NCT04825028.

Project description:Purpose To compare the prognostic importance (time to major adverse cardiovascular event [MACE]) of combined computed tomography (CT) angiography and CT myocardial stress perfusion imaging with that of combined invasive coronary angiography (ICA) and stress single photon emission CT myocardial perfusion imaging. Materials and Methods This study was approved by all institutional review boards, and written informed consent was obtained. Between November 2009 and July 2011, 381 participants clinically referred for ICA and aged 45-85 years were enrolled in the Combined Noninvasive Coronary Angiography and Myocardial Perfusion Imaging Using 320-Detector Row Computed Tomography (CORE320) prospective multicenter diagnostic study. All images were analyzed in blinded independent core laboratories, and a panel of physicians adjudicated all adverse events. MACE was defined as revascularization (>30 days after index ICA), myocardial infarction, or cardiac death; hospitalization for chest pain or congestive heart failure; or arrhythmia. Late MACE was defined similarly, except for patients who underwent revascularization within the first 182 days after ICA, who were excluded. Comparisons of 2-year survival (time to MACE) used standard Kaplan-Meier curves and restricted mean survival times bootstrapped with 2000 replicates. Results An MACE (49 revascularizations, five myocardial infarctions, one cardiac death, nine hospitalizations for chest pain or congestive heart failure, and one arrhythmia) occurred in 51 of 379 patients (13.5%). The 2-year MACE-free rates for combined CT angiography and CT perfusion findings were 94% negative for coronary artery disease (CAD) versus 82% positive for CAD and were similar to combined ICA and single photon emission CT findings (93% negative for CAD vs 77% positive for CAD, P < .001 for both). Event-free rates for CT angiography and CT perfusion versus ICA and single photon emission CT for either positive or negative results were not significantly different for MACE or late MACE (P > .05 for all). The area under the receiver operating characteristic curve (AUC) for combined CT angiography and CT perfusion (AUC = 68; 95% confidence interval [CI]: 62, 75) was similar (P = .36) to that for combined ICA and single photon emission CT (AUC = 71; 95% CI: 65, 79) in the identification of MACE at 2-year follow-up. Conclusion Combined CT angiography and CT perfusion enables similar prediction of 2-year MACE, late MACE, and event-free survival similar to that enabled by ICA and single photon emission CT. © RSNA, 2017 Online supplemental material is available for this article.

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Prognostic Value and Therapeutic Perspectives of Coronary CT Angiography: A Literature Review.

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Prognostic Value and Therapeutic Perspectives of Coronary CT Angiography: A Literature Review.

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