The hard task of the anatomic characterization in improving the prognostic stratification of CAD

Abstract

Starting the first evidences reporting the role of coronary computed tomography angiography (CCTA) in improving the prognostic stratification of patients with suspected coronary artery disease (CAD) [ [1] Maffei E. Seitun S. Martini C. et al. Prognostic value of computed tomography coronary angiography in patients with chest pain of suspected cardiac origin. Radiol. Med. 2011; 116: 690-705 Crossref PubMed Scopus (27) Google Scholar ], there is a growing interest in testing the correlation between the non-invasively assessed coronary plaque features and the occurrence of major adverse cardiac events (MACE). In keeping with this trend, Andreini et al. [ [2] Andreini D. Pontone G. Mushtaq S. et al. Long-term prognostic impact of CT-Leaman score in patients with non-obstructive CAD: results from the COronary CT Angiography EvaluatioN For Clinical Outcomes InteRnational Multicenter (CONFIRM) study. Int. J. Cardiol. 2017; 231: 18-25 Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar ] evaluated the ability of CT-adapted Leaman score (CT-LeSc), built considering localization of the coronary plaques, type of plaque (calcified, non calcified, and mixed), and degree of stenosis, to assess long-term prognosis of patients with non-obstructive CAD. Although the study showed that CT-LeSc score was an independent predictor of MACE, the results seem to be not enough compelling. Namely, the independent predictors of myocardial infarction plus all-cause death at multivariate analysis in models 1 and 3 were non-obstructive CAD with a CT-LeSc≤5 (HR 2.05 and 1.55, respectively) and non-obstructive CAD with a CT-LeSc>5 (HR 2.48 and 1.94, respectively). In my personal view, the fact that the CT-LeSc does not take in consideration some of the more advanced plaque features, like positive remodeling, low attenuation plaque, and napkin-ring sign, justifies the dim robustness of this score. Indeed, numerous studies demonstrated a strong link of the abovementioned features to outcomes [ 3 Motoyama S. Ito H. Sarai M. et al. Plaque characterization by coronary computed tomography angiography and the likelihood of acute coronary events in mid-term follow-up. J. Am. Coll. Cardiol. 2015; 66: 337-346 Crossref PubMed Scopus (500) Google Scholar , 4 Guaricci A.I. Pontone G. Brunetti N.D. et al. The presence of remodeled and mixed atherosclerotic plaques at coronary ct angiography predicts major cardiac adverse events — the CAFÉ-PIE study. Int. J. Cardiol. 2016; 215: 325-331 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar , 5 Guaricci A.I. Pontone P. Fusini L. et al. Additional value of inflammatory biomarkers and carotid artery disease in prediction of significant coronary artery disease as assessed by coronary computed tomography angiography. Eur. Heart J. Cardiovasc. Imaging. Oct 14 2016; https://doi.org/10.1093/ehjci/jew173 Crossref PubMed Scopus (27) Google Scholar ]. The effort of Andreini et al. is greatly appreciated and their study represents a step forward in understanding of primary prevention strategy. At the same time, it testifies the difficulties of making a comprehensive evaluation for this purpose.