Computed Tomography Angiography Research Articles

Assessing the need for coronary angiography in high-risk acute coronary syndrome patients using artificial intelligence and computed tomography

Abstract Background/Introduction The use of coronary computed tomography angiography (CCTA) in managing high-risk acute coronary syndrome (ACS) patients is increasingly common. Yet, its role remains unvalidated in this context, posing challenges to traditional clinical decision-making algorithms. Physicians, accustomed to a hierarchical and structured approach involving symptom assessment, electrocardiograms, and biomarkers for deciding on the necessity of invasive coronary angiography (ICA), now face dilemmas when CCTA results challenge established diagnostic pathways and contradict clinical decisions based on usual criteria. Meanwhile, the potential of artificial intelligence (AI) which processes information in a way fundamentally different from human clinical reasoning, has been shown to aid decision-making in cardiovascular medicine. Yet, it has not been tested in this acute setting. Purpose This study aimed to evaluate the efficacy of the Chat Generative Pre-trained Transformer (ChatGPT) in guiding the need for ICA in high-risk ACS patients based on both standard clinical data and CCTA findings. Methods This investigation is a sub-study of a larger research project where high-risk ACS patients (all having a theoretical guideline-based indication for ICA) underwent CCTA prior to ICA. ChatGPT analyzed clinical vignettes containing patient data, electrocardiograms, troponin levels, and CCTA results to determine the necessity of ICA. The AI's recommendations were then compared to actual ICA findings to assess its decision-making accuracy. Results Among 86 patients with a clear indication for ICA, ChatGPT recommended against it for 19 patients, 16 of whom indeed had no significant findings at ICA (Figure). For 67 patients, ChatGPT advised proceeding with ICA, and a significant lesion was confirmed in 58 of them. Consequently, ChatGPT's overall accuracy stood at 86%, with a sensitivity of 95% and a specificity of 64%. The model's negative predictive value was 84%, and its positive predictive value was 87%. Conclusion These preliminary data suggest that ChatGPT can effectively assist in guiding the need for ICA among high-risk ACS patients, potentially reducing unnecessary procedures but further clinical studies to refine AI's role in clinical decision-making are required.ChatGPT's decision as per ICA's results

Association between high versus low cardiovascular risk in individuals with corresponding unexpected absent versus severe subclinical coronary atherosclerosis, a nationwide, multicenter study

Abstract Background It remains unclear as to why some individuals at low risk of cardiovascular disease (CVD) develop severe coronary atherosclerosis, while those at high CVD risk may remain free from coronary atherosclerosis. Purpose Using Coronary Computed Tomography Angiography (CCTA), we aimed to identify factors associated with absence and severe coronary atherosclerosis in subjects from the general population with very high and low-moderate CVD risk, respectively. Methods We assessed cross-sectionally a nationwide, multicenter population-based cohort, consisting of 30,154 individuals randomly recruited from the general population (age range 50-64 years, 51.4% women). Coronary calcified plaque burden was estimated by coronary artery calcium score (CACS) assessed by CCTA. Absent coronary atherosclerosis was defined as CACS 0 and severe coronary atherosclerosis was defined as CACS ≥301. We investigated only individuals with low-moderate (<5%) and very high CVD risk (≥10%) according to SCORE2 were included. Individuals with CACS 0 and prevalent CVD were excluded, as well as those with moderate CACS (1-300) or SCORE2 risk 5-9%. Out of 26 722 subjects with complete data on CACS and SCORE2, 13 075 were included. Logistic regression was performed adjusted for age and sex. Results The overall distribution of CACS in relation to SCORE2 CVD risk is illustrated in the Figure. Study characteristics are displayed in Table 1. Severe-extensive CACS in combination with low-moderate CVD risk was present in 2.3% (n=296). A further 2.3% (n=311) had very high CVD risk but CACS 0. Factors associated with CACS 0 despite a very-high estimated CVD risk included: lower age, being female, being born in Sweden, not having hypertension or hyperlipidemia, fewer pack-years of smoking, and lower waist circumference in men. On the contrary, severe-extensive CACS despite a low-moderate estimated CVD risk was associated with higher age, being male, being an ex-smoker, reporting more pack-years of smoking, having higher HbA1c, higher BMI, higher waist circumference, and prevalent hyperlipidemia and hypertension (Table 2). Conclusions We identified extreme cardiovascular risk phenotypes (subgroups) in the general population that either lacked coronary calcifications despite being at very high estimated CVD risk or had severe subclinical coronary atherosclerosis despite being at estimated low-moderate CVD risk. Further studies are warranted to elucidate putative enhancing or protective mechanisms explaining this unexpected phenomenon.

Interscan reproducibility of computed tomography derived coronary plaque volume measurements using a semi-automated analysis software

Abstract Background Coronary computed tomography angiography (CCTA) enables detailed quantification and characterization of coronary atherosclerotic plaque, offering diagnostic and prognostic value. Despite the growing demand for accurate plaque analysis, studies on interscan reproducibility of automated plaque quantification are limited in number and size. Moreover, impact of clinical and technical factors on the reproducibility of plaque assessment tools are scarce. Purpose The objective of this study was to assess the interscan reproducibility of CCTA-derived plaque volume measurements and the implications of clinical and technical characteristics on interscan reproducibility. Methods A total of 101 patients with known coronary artery disease underwent two CCTA scans within hour interval using identical CT acquisition protocol. Coronary plaque volume measurements were quantified on a per-patient level using a contemporary semi-automated plaque analysis software. Results There was no statistically significant difference in median plaque volumes between the first and second scan. The direct correlation was excellent for volumes of non-calcified plaque (NCP), calcified plaque (CP), and total plaque (TP) across all analyses (Pearson’s coefficient 0.96 to 0.99), while moderate for low-density non-calcified plaque (LD-NCP) volumes (Pearson’s coefficient 0.77). Bland Altman analyses demonstrated high interscan agreement with narrow absolute and relative limits of agreement (LoA) across plaque subtypes, except for LD-NCP volumes (Table 1). Interscan reproducibility on CP volumes was affected by CT image quality with narrower LoA in scans with the highest image quality score (p = 0.003), or lowest image reconstructive iteration level (p <0.001). Limits of agreement were significantly narrower for NCP, CP, and TP volumes in lesions located in LAD compared to non-LAD lesions (p <0.001). However, no significant difference in LoA was present when comparing patients according to BMI (<27 and ≥27 kg/m2), heart rate (<65 and ≥65 beats per minute), or Agatston score (<193 and ≥193). Conclusions This comprehensive interscan reproducibility study revealed good agreement in the measurement of plaque subtypes. Adding new insight to existing literature, we have demonstrated that factors such as image quality, image reconstructive algorithms, and lesion location affect the reproducibility of plaque volume measurements. CT-derived plaque quantification using a semi-automated plaque analysis software holds potential for monitoring disease progression or regression in patients with CAD, provided high CCTA image quality.

Gender differences in the use of coronary computed tomography angiography, functional testing, coronary angiography, revascularization, and outcomes - a 10-year Danish, nationwide, registry-based foll

Abstract Background and aims Coronary computed tomography angiography (CCTA) serves as a noninvasive imaging modality, that guides downstream preventive and invasive treatment. However, differences in its use in relation to gender has not been investigated. Methods This nationwide register-based cohort study investigated all residents in Denmark between 2008 and 2018, consisting of individuals aged 50-80 years without coronary artery disease (CAD). The study population was stratified into male and female cohorts (n = 1469724). The outcomes included CCTA, functional testing, invasive coronary angiography (ICA), myocardial infarction (MI), revascularization, and major adverse cardiovascular and cerebrovascular events (MACCE). Results Among individuals who underwent CCTA, a slightly higher use was observed among females (absolute risk [AR] 4.2% individuals aged ≥50-59 years, AR 4.1% individuals aged ≥60-69 years, and AR 2.3% individuals aged ≥70-80 years) compared to males (absolute risk [AR] 4.0% individuals aged ≥50-59 years, AR 3.6% individuals aged ≥60-69 years, and AR 2.3% individuals aged ≥70-80 years). Conversely, the use of functional testing, were lower among females (AR 4.5% individuals aged ≥50-59 years, AR 5.2% individuals aged ≥60-69 years, and AR 4.3% individuals aged ≥70-80 years) compared to males (AR 6.2% individuals aged ≥50-59 years, AR 7.1% individuals aged ≥60-69 years, and AR 6.3% individuals aged ≥70-80 years), similar differences were observed for ICA, revascularization, MI risks, and MACCE. Conclusion Men were less likely to undergo CCTA compared to women. Conversely, use of functional testing, ICA, and revascularization along with an increased risk of MI or MACCE were higher in men.Figure 1

Variability of pre-test probability for obstructive coronary artery disease between referring primary care physicians and estimations from the referral letters

Abstract Background Estimation of Pre-Test Probability (PTP) for obstructive Coronary Artery Disease (CAD), derived from sex, age and characterization of chest pain or dyspnea, is recommended by European guidelines to guide further investigation. When Coronary Computed Tomography Angiography (CCTA) was introduced as first line investigation in patients with PTP <15%, in the primary care of a catchment area of ~470 000 inhabitants in Sweden, attachment of PTP was made compulsory to the referral. The interrater variability, or consistency of agreement, of PTP estimation is not known. The validity of PTP to guide healthcare decisions depends to some extent on the reliability of estimations. Appropriate prioritization of invesigations is reliant on the information included in referral letters. Purpose The purpose was to study the interrater variability of estimations of PTP. We hypothesized: 1) the interrater variability of PTP estimations to be less than excellent (ICC < 0.9), and 2) not statistically different among PTP classes; 3) a significant difference between clinical estimations and estimations made from the referral letters. Methods We studied the 545 patients referred for CCTA from primary care, 1st of June 2021 to 7th of Dec. 2022, with available PTP estimations. The interrater variability, expressed as Intraclass Correlation Coefficients (ICC), was determined for estimations of PTP by the referring physicians (RP) and three external raters (ER). The latter were physicians practising in primary care who rated PTP based on the referral letters to CCTA, independently and blinded. Each rater assessed multiple patients and each patient was assessed by all raters. ICC with a two-way random consistency model for single raters was calculated and evaluated according to a proposed standard(1). Results The ICC for PTP estimations between the RP and the median of three ER was 0.75 (CI 95 % 0.71-0.83, p<0.001). ICC was higher for PTP class > 15% compared to the lower classes: <5% (n = 65, ICC ≈ 0); 5-15% (n = 343, ICC 0.48, CI 95 % [0.39-0.56]); >15% (n = 137, ICC 0.71, CI 95 % [0.62-0.78]) (Figure 1). The ICC for PTP estimations was significantly higher between the three ER (0.88, SE 0.009, CI 95% [0.86-0.89]) than when the RP was added as a rater (ICC 0.80, SE 0.012, CI 95 % [0.77-0.82]). Adding a fixed effect of the difference in ratings between RP and ERs to the ICC model did not change model output (R = 0.80 (SE 0.012, CI 95 % [0.77-0.82]). Conclusions There is a good repeatability, in estimation of PTP based on medical history as described in referral letters, between blinded independent reviewers of CCTA referrals. The repeatability between the external raters and the referring physicians’ compulsory entered PTPs is lower, yet good. The variability of PTP estimations, speculatively from disagreement on main symptom and inconsistency in characterization of chest pain, may impact patient selection and outcomes and is understudied.

Association of non-invasive assessed anatomical features with functional testing in coronary artery anomalies - NARCO trial

Abstract Introduction Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital condition believed to carry an increased risk for myocardial ischemia. However, correlation between anatomical characteristics and ischemia remains unclear. Therefore, this study aimed to assess: 1. The difference of invasive fractional flow reserve (FFR) and intravascular ultrasound (IVUS)-based minimal lumen area (MLA) between baseline and stress. 2. The association of coronary computed tomography angiography (CCTA)-based anatomical characteristics to invasively measured hemodynamics and IVUS in AAOCA. Methods Consecutive patients with AAOCA and presence of ≥1 anatomical high-risk features (i.e. intramural course (IM), slit-like ostium, acute take-off angle or proximal narrowing), were systematically evaluated as part of the NARCO trial using CCTA, FFR using adenosine (140 µg/kg/min), dobutamine-volume stress (20-40mcg/kg/min, 0.5-1mg atropine and 3L of saline solution) and IVUS- MLA of IM. Anatomic high-risk features were quantified by CCTA including ostial lumen area and IM-MLA, IM-width, IM-height, IM-elliptic ratio, take-off angle, proximal narrowing and IM length of the anomalous coronary segment. Results A total of 94 patients with AAOCA were screened, whereas 48 showed high-risk anatomic features and underwent the complete stress protocol. Mean age was 54±12 years and 36 (75%) were male and 39 (81%) presented with symptoms. FFRstress was significantly lower than FFRadenosine (0.88 [0.81-0.91] vs. 0.91 [0.87-0.94], p<0.001) (Figure 1). FFRadenosine was ≤0.8 in 5 patients (10%), and FFRdobutamine was ≤0.8 in 12 patients (25%), resulting in 7 (15%) with FFRadenosine >0.8 while FFRdobutamine was ≤0.8. IVUS-MLA was decreased from 6.3 (5.4-8.2) mm2 to 5.4 (4.2-7.1) mm2 during stress (p<0.001) (Figure 2), while elliptic ratio increased from 2.6 (2.1-3.4) to 3.3 (2.5-4.4) (p<0.001). Logistic regression analysis for body surface area adjusted CCTA derived high-risk features showed, that only ostial lumen area, IM-MLA, -elliptic ratio and -width could predict FFRstress ≤0.8. Receiver operating curve analysis showed that ostial width had the greatest AUC with 0.86 (accuracy 83%, sensitivity 83%, and specificity 83%). Eight out of 12 (67%) patients with hemodynamic relevance underwent surgery, 2 (17%) underwent stenting and 2 (17%) were treated with medication. Conclusion In patients with AAOCA and anatomic high-risk features, only one quarter are hemodynamic relevant. FFR during dobutamine-volume stress showed to be the more sensitive stress modality as compared to FFRadenosine. CCTA derived ostial and IM anatomical severity is associated with ischemia under stress. Comprehensive functional and anatomical assessment of AAOCA helps to optimize patient management and avoid unnecessary revascularization.Figure 1:FFRadenosine vs FFRstressFigure 2:IVUS-MLArest vs IVUS-MLAstress

Influence of coronary plaque characteristics on lesion-specific ischemia assessed by coronary computed tomography angiography and fractional flow reserve - a systematic review and meta-analysis

Abstract Background Characterization of atherosclerotic plaque features by coronary computed tomography angiography (CCTA) carries profound prognostic value. Previous studies indicate that coronary plaque burden and certain plaque features are associated to lesion-specific ischemia by invasive fractional flow reserve (FFR). However, the existing literature is limited by small sample sizes, and provide inconsistent results. Purpose We performed a meta-analysis in order to delineate further the potential association between coronary plaque phenotype by CCTA and FFR. Methods A comprehensive systematic literature review and meta-analysis was conducted. PubMed and Embase databases were searched for studies that investigated the association between coronary plaque characteristics and FFR between January 2010 and August 2023. Study search, evaluation, and data extraction were performed independently by two researchers. Weighted mean difference (WMD) method for WMD was used for comparison of pooled per-lesion plaque parameters and presence of specific plaque features against presence of lesion-specific ischemia (FFR ≤0.80). Lesions with stenosis severity of 25-90% were included. Extracted data from eligible studies were analysed using random effects model for WMD and to estimate odds ratios (OR) with 95% confidence intervals (CI). Results A total of 12 studies were deemed eligible with 1,318 patients and available data on 1,915 coronary lesions. Of these, 626 lesions caused ischemia. Significantly greater total plaque volume (TPV) and non-calcified plaque volume (NCPV) occurred in lesions with abnormal FFR compared to normal FFR (WMD 83.0 mm3, 95% CI: 44.27; 121.81, p<0.001; WMD 83.63 mm3, 95% CI: 55.0; 112.24, p <0.001, respectively). Similar findings were observed for aggregate plaque volume (%APV) and plaque burden (%PB) with WMD 9.18, 95% CI: 6.08; 12.28, p<0.001; WMD 8.83, 95% CI: 4.32; 14.24, p=0.001, respectively. Napkin ring-sign and spotty calcification appeared more frequent in ischemia-causing lesions compared to those with FFR >0.80 (OR 4.25, 95% CI: 1.39; 13.00, p=0.011; OR 1.92, 95% CI: 1.33; 2.75, p=0.001, respectively). A summary of the meta-analysis findings regarding the association between plaque burden and plaque characteristics and FFR is provided in Figure 1 and 2. Conclusion CCTA-derived TPV and NCPV as well as %APV, %PB and the presence of napkin-ring sign and spotty calcification are associated with presence of lesion-specific ischemia. Coronary plaque assessment from CCTA images provide improved discrimination of lesion-specific ischaemia.

Relationship between plaque burden and plaque vulnerability in patients with acute coronary syndromes versus chronic coronary syndrome

Abstract Background The relationship between plaque burden and plaque vulnerability based on clinical presentations has not been fully investigated. Objective The aim of this study was to compare the relationship between plaque burden and plaque vulnerability in patients with acute coronary syndromes (ACS) versus chronic coronary syndrome (CCS). Methods This is an observational, single-center cohort study. Patients who underwent both coronary computed tomography angiography (CTA) and optical coherence tomography (OCT) before coronary intervention were enrolled. All OCT and CTA images were analyzed at the core laboratory. All plaques were detected in culprit vessels using CTA, and total plaque volume (TPV) and OCT features were assessed at the corresponding sites. A layered plaque was defined as a plaque with one or more layers of different optical densities and a clear demarcation from underlying components. The layer arc was measured at 1-mm intervals. The layer index, which is equivalent to layer volume, was defined as mean layer arc × layer length. All plaques were divided into three groups according to the tertile range of TPV (low TPV: <96.5 mm3, moderate TPV: 96.5 – 164.7 mm3, high TPV: ≥164.8 mm3). The effect modification of clinical presentations (CCS or ACS) on the association between TPV and OCT features was investigated. Results A total of 990 plaques were imaged by OCT in 419 patients: 445 plaques in 190 (45.3%) patients who presented with ACS and 545 in 229 (54.7%) with CCS. The prevalence of thin-cap fibroatheroma (TCFA) was higher as plaque volume increased in both groups (low vs. moderate vs. high TPV group: 18.4% vs. 37.8% vs. 52.3% in ACS; 16.2% vs. 19.9% vs. 30.6% in CCS; interaction P=0.066). However, the effect modification of clinical presentations on the associations of TPV with macrophage, lipid arc, and layer index was statistically significant. Macrophage was more prevalent in plaques with greater TPV in patients who presented with ACS but not in those who presented with CCS (low vs. moderate vs. high TPV group: macrophage 57.4% vs. 71.8% vs. 82.4% in ACS; 63.4% vs. 67.8% vs. 66.7% in CCS; interaction P=0.004). Lipid arc was more strongly associated with TPV in patients who presented with ACS than in those with CCS (low vs. moderate vs. high TPV group: 116 [76-157] vs. 166 [115-210] vs. 175 [140-221] in ACS; 118 [80-154] vs. 143 [102-187] vs. 150 [102-199] in CCS; interaction P=0.028). Conversely, layer index was more weakly associated with TPV in patients who presented with ACS than in those who presented with CCS (low vs. moderate vs. high TPV group: 0 [0-0] vs. 0 [0-365] vs. 0 [0-903] in ACS; 0 [0-756] vs. 235 [0-1266] vs. 552 [0-1704] in CCS; interaction P=0.046) (Figure 1). Conclusions Greater plaque burden was closely related to the level of plaque vulnerability in ACS, whereas this relationship was less obvious in CCS.Figure 1

Lead-related tricuspid regurgitation: an important phenotype seen through the lens of computed tomography

Abstract Background The imaging diagnostic approach of patients with cardiac implantable electronic devices (CIED)-related tricuspid regurgitation (TR) is undefined. Functional cardiac computed tomography angiography (4D-CTA) provides a complementary role to echocardiography in the evaluation of tricuspid valve (TV) apparatus and right ventricle (RV) remodeling, but the capability to assess lead-leaflet interaction is unknown. Purpose To evaluate the role of 4D-CTA anatomical and morphological diagnostic assessment in a cohort of patients with severe TR and CIED vs those without. Methods Clinical, echocardiographic and CTA data were collected from two quaternary centers for patients with severe TR and a CIED evaluated between January 2017 to October 2023. Functional and morphological CTA information assessed lead-leaflet relationship to divide patients in those with lead-related TR, those with no lead-TR causal relationship, and those with severe isolated TR but without CIED. Primary end-point was the occurrence of all-cause death. Results A total of 143 patients were identified, roughly dividng the cohort into thirds. Baseline characteristics and imaging characteristics of these 3 groups revealed important differences suggesting a more advanced patophysiology phenotype for those with lead-related TR, particularly presenting both the largest 4D-CTA-derived TV maximum coaptation gap and anatomical regurgitant orifice area (see Figure 1). At regression analysis, time from CIED implantation (OR 1.01, CI 1.00-1.09, p=0.031) and >3 leaflets valve morphology (OR 2.90, CI 1.01-8.32, p=0.040) were independently associated with lead-related TR. After a median follow-up of 18 months, the primary end-point occurred in 36 patients (25%) and was more common among patients with lead-related TR (p-value overall= 0.007, see Figure 2). While no differences in the rate of TV intervention were found, excessive mortality persisted for lead-related TR group even after adjustement for age and gender (HR 6.49, CI 1.72-14.47, p=0.006). Conclusion Systematic 4D-CTA in patients with severe TR and presence of a CIED, identified a large number of patients with lead-related TR with important functional and anatomical implications including greater TR severity and > 3 leaflets. These findings appear to have prognostic relevance that might have decision-making implications for patient management.Figure 1Figure 2

Predictive value of plaque characteristics assessed by coronary computed tomography angiography and optical coherence tomography for identification of lesions causing ischemia

Abstract Background In patients with intermediate coronary stenosis, the functional assessment with fractional flow reserve (FFR) and the anatomical assessment with optical coherence tomography (OCT) have been widely used in clinical practice. Additionally, coronary computed tomography angiography (CTA) is commonly used non-invasive imaging technique for evaluating suspected coronary artery disease before being referred for angiography. Objectives This study sought to investigate the association between FFR and plaque characteristics assessed by coronary CTA and OCT in intermediate coronary stenosis. Methods Based on the prospective multicentre registry, a total of 159 patients including 339 coronary lesions with intermediate stenosis were included. All patients underwent coronary CTA before being referred for coronary angiography and both FFR measurement and OCT examination were performed during angiography. The stenotic lesion with FFR ≤0.80 was considered diagnostic of lesion causing ischemia. The predictive value of plaque characteristics assessed by coronary CTA and OCT for identifying lesions causing ischemia was analyzed. Results Stenosis severity and plaque characteristics on coronary CTA and OCT were different between the lesions causing ischemia versus not causing ischemia. On multivariate analysis, low attenuation plaque on coronary CTA (odds ratio [OR]= 2.78; P=0.038) and thrombus (OR=5.13; 0.042), plaque rupture (OR=3.25; P=0.017), and intimal vasculature on OCT (OR=2.57; P=0.012) were independent predictors for the lesions causing ischemia. Increasing number of these plaque characteristics offered incremental improvement in predicting the lesions causing ischemia. Conclusions Comprehensive anatomical evaluation of coronary stenosis may be able to provide additional supportive information for predicting the lesions causing ischemia.

Diagnostic performance of coronary computed tomography angiography for coronary in-stent re-stenosis

Abstract Background Through the development of CT equipment and proper preparation before CT scanning, the accuracy of Coronary computed tomography angiography (CCTA) diagnosis of ischemic heart disease (IHD) is improving, and the role of CCTA in treatment decision is gradually expanding. The latest guidelines recommend CCTA as Class IIa to evaluate stent patency and native vessels in patients with chronic coronary disease. However, diagnostic performance of CCTA to evaluate stent patency in patients who underwent coronary stent was not clarified, respectively the role of CCTA in the evaluation of IHD in native coronary artery was established.. Purpose In the present study, we evaluate the agreement between CCTA and CAG in assessing stent patency in patients with de novo ischemic chest pain who underwent percutaneous coronary intervention (PCI) and evaluated which factors contribute to the differences. Methods From January 1, 2010 to December 31, 2020, we analyzed 845 patients who underwent new CCTA and CAG sequentially for the evaluation of chest pain previously underwent PCI. In CAG and CCTA, ISR is equally defined as a stenosis greater than 50% of the vessel diameter of within the stented segment or its edge (5-mm segments adjacent to the stent). The degree of In-stent restenosis was analyzed by an independently by quantitative coronary angiography (QCA). Results A total of 208 stents were analyzed, the pooled sensitivity and specificity for CCTA on the diagnosis of ISR were 0.78 (0.65-0.89) and 0.93 (0.88-0.96), respectively. LR+ and LR- were 11.19 (6.22-20.15) and 0.23 (0.14-0.39). As a result of analyzing the ISR diagnostic agreement of CCTA by dividing into ACS and CCD group, the agreement of CCTA for ISR diagnosis was relatively low in the ACS group (Sensitivity 0.69 (0.48-0.86) vs. 0.88 (0.69-0.97), specificity 0.92 (0.84-0.97) vs. 0.94 (0.86-0.98), LR+ 9 (4-20.24) vs. 13.9 (5.88-32.88), LR- 0.33 (0.19-0.6) vs. 0.13 (0.04-0.37)) (Table 1). As a result of analyzing related factors in cases of discrepancy in ISR diagnosis, the degree of stenosis in both ACS and CCD groups was mostly intermediate stenosis, which often required additional clinical evaluation (Figure 1). Conclusion When new ischemic chest pain occurred in a patient who previously underwent PCI, the diagnostic accuracy of ISR by CCTA differed depending on the patient’s IHD category. In the CCD group, the diagnostic usefulness of CCTA was comparable both native vessels and ISR, but not in the ACS group. As majority of ISR diagnostic discrepancies were in intermediate lesions, even in the ACS group, CCTA may be considered as a diagnostic tool.

Favorable impact of FFRCT on myocardial revascularization outcomes: results from an observational real-world registry

Abstract Background Based on excellent clinical outcomes data, coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) is endorsed by guidelines to diagnose obstructive coronary artery disease (OCAD)(1). Dedicated outcome analyses in revascularized patients are essential to assess the additional value of FFRCT in revascularization. Purpose To assess the impact of FFRCT use on the postprocedural myocardial injury (PMI) and long-term outcomes of patients with OCAD undergoing myocardial revascularization. Methods Patients with suspected OCAD on CCTA (at least one stenosis of >50% in any vessel) were included from a 2013-2021 tertiary hospital registry. Propensity score adjusted Cox- regression and logistic regression analysis were used to assess the impact of FFRCT on the outcomes of OCAD patients post-revascularization. PMI was defined as cardiac troponin (cTn)>5 times the 99th percentile URL for percutaneous coronary intervention (PCI) and cTn>10 times the 99th percentile URL for coronary artery bypass graft (CABG) (2). Major adverse cardiovascular events (MACE) comprised all – cause mortality, acute myocardial infarction (AMI), stroke, hospitalization for heart failure (HHF) and new revascularization. Results From a registry of 7541 patients, suspected CCTA - derived OCAD was reported in 1601 cases. 559 OCAD patients were revascularized: 386(69.05%) by PCI, 166(29.7%) by CABG and 7(1.25%) by PCI and CABG. FFRCT was performed in 252(45.1%) patients. During a follow-up of 4.4±2.2 years, MACE occurred in 137(24.5%) patients: 43(7.7%) died, 21(3.8%) patients were hospitalized for AMI, 14(2.5%) patients had a stroke, 12 (2.1%) patients had HHF and 77(13.8%) patients had a new revascularization. Survival analysis indicated significant differences in MACE and all-cause mortality–rates between FFRCT use and no FFRCT use (log- rank p = 0.033 and 0.004, Fig 1). Multivariable propensity–adjusted Cox–regression analysis showed a non–significant trend towards reduced MACE risk by using FFRCT (HR 0.736, 95% CI 0.513-1.055, P=0.095) and a significant reduction in all-cause mortality risk (HR 0.476, 95% CI 0.230–0.985, P=0.046). Sub-analysis in the PCI and CABG groups showed no significant association between FFRCT and MACE. Among the 477 patients with available cTn values, 203 (42.5%) had PMI. In the CABG group, FFRCT use correlated with low PMI incidence (5.3% vs. 15.6%, p=0.044). However, multivariable Cox regression analysis revealed no significant association between FFRCT use and PMI(Fig 2). Conclusion This observational designed study reveals for the first time that FFRCT reduces post-myocardial revascularization MACE, primarily driven by reduced all-cause mortality. No clear reduction of PMI was observed suggesting that FFRCT value extends beyond procedural enhancements. Although derived from a large real-world registry, these promising observations need to be confirmed by randomized studies.Figure 1Figure 2

Increased prevalence of coronary atherosclerosis in cancer survivors: a matched cross-sectional study with coronary CT angiography

Abstract Background Cancer and atherosclerosis share many risk factors. Although cardiovascular disease is highly prevalent among cancer survivors, it is unknown whether coronary atherosclerosis is present at a younger age in patients with a history of cancer. Purpose The purpose of this study is to evaluate the prevalence of coronary atherosclerosis in different age groups of patients with a history of cancer compared to matched controls. Methods Consecutive patients with a history of cancer aged >30 years who underwent evaluation for coronary artery disease with coronary computed tomography angiography (CCTA) between 2010 and 2023 were included in this cross-sectional study. Patients with a history of cancer were matched 1:2 to a control population without oncological history using propensity score matching. Patients were matched on age, gender, body mass index, hypercholesterolemia, hypertension, diabetes, use of statins and smoking status. The presence of atherosclerosis in the main coronary arteries was compared between the groups. Results The study population consisted of 313 patients with an oncological history and 626 matched control patients. The median age during CCTA scan was 59.4 [50.4-67.5] years and 66.1% of the patients were female. Coronary atherosclerosis was observed in 258 (82.4%) patients with a history of cancer compared to 461 (73.6%) control patients with a risk ratio of 1.12 [95% CI: 1.04-1.20], p<0.01. Mainly younger patients with a history of cancer aged between 30-59 years had a significant increased prevalence of coronary atherosclerosis with a risk ratio of 1.18 [1.04-1.33] compared to healthy controls (p=0.02). In our study population, thoracic radiotherapy was not associated with an increased prevalence of coronary atherosclerosis. Calcified plaques were observed more frequently in patients with a history of cancer (14.4% vs. 9.3% respectively, p=0.018). Conclusion Patients with a history cancer have a higher prevalence of coronary atherosclerosis as observed on CCTA compared to matched patients without cancer. This effect was most pronounced in younger patients aged 30-59 years. There is an unmet need to define strategies for cardiovascular disease monitoring and prevention in this growing patient population of patients with a history of cancer.Presence of coronary atherosclerosisRadiotherapy and atherosclerosis

Effects of nicorandil, isosorbide mononitrate or diltiazem on radial artery grafts after coronary artery bypass grafting: the randomized ASRAB-pilot trial

Abstract Background The optimal chronic oral antispastic medication after coronary artery bypass grafting (CABG) using radial artery (RA) grafts is controversial. Purpose This pilot trial aimed to preliminarily compare the efficacy and safety of nicorandil, isosorbide mononitrate, or diltiazem in patients who underwent CABG using RA grafts. Methods This was a single-center, randomized, open-label, parallel-group pilot trial. Eligible patients who underwent CABG using RA grafts within 3 days were randomized in a 1:1:1 ratio to receive oral doses of nicorandil (15 mg daily), isosorbide mononitrate (50 mg daily), or diltiazem (180 mg daily) for 24 weeks post-CABG. The primary outcomes were RA grafts failure (defined as modified FitzGibbon Grade B, S, or O) at 1- and 24-weeks, assessed by coronary computed tomography angiography (CCTA). The secondary outcomes include major adverse cardiovascular event (MACE, a composite of all-cause death, myocardial infarction, stroke, and unplanned revascularization) and angina recurrence. Results Among 150 randomized participants, 149 patients (full analysis set, mean age 56.8 years, 13.4% females, 83.9% with acute coronary syndrome, 49.7% with diabetes) with 177 RA grafts completed at least once CCTA assessment, including 50 patients with 64 RA grafts in the nicorandil group, 50 patients with 57 RA grafts in the isosorbide mononitrate group, and 49 patients with 56 RA grafts in the diltiazem group, respectively. (Figure 1). At 1-week post-CABG, the RA graft failure rates were numerically lower with nicorandil vs. diltiazem (19.4% vs. 25.0%, difference: -5.6% [95% CI -20.6% to 9.3%]; P = 0.49) and isosorbide mononitrate vs. diltiazem (18.2% vs. 25.0%, difference: -6.8% [95% CI -21.8% to 8.6%]; P =0.41). Nicorandil vs. isosorbide mononitrate showed similar rates (19.4% vs 18.2%, difference: 1.2% [95% CI −13.3% to 15.2%]; P =0.88). At 24 weeks, a numerically trend indicating a larger reduction in RA graft failure rates between nicorandil vs. diltiazem (16.1% vs 27.8%, difference: -11.7% [95% CI -26.6% to 3.4%]; P =0.17), and isosorbide mononitrate vs. diltiazem (12.5% vs 27.8%, difference: -15.3% [95% CI -29.8% to -0.2%]; P =0.06). Nicorandil vs. isosorbide mononitrate remained similar (16.1% vs 12.5%, difference: 3.6% [95% CI -9.6% to 16.4%]; P =0.59). Per-protocol set analysis results were consistent with full analysis set analysis (Table 1). During the follow-up, 6 patients with MACEs and 7 with angina recurrence were observed (MACE: 2 in nicorandil, 2 in isosorbide mononitrate, and 2 in diltiazem; angina recurrence: 1, 3, and 3 in the respective groups). Conclusions In this underpowered pilot trial, treatment with nicorandil or isosorbide mononitrate showed a numerically considerable but not statistically significant benefit on RA grafts outcome compared to diltiazem up to 24-week post-CABG. Larger hypothesis testing trial is warranted.Figure 1:The study flow diagramFigure 2:Primary outcomes in FAS and PP

Coronary atherosclerotic plaque burden and characterization by spectral computed tomography scan in patients with high lipoprotein a and non-hemodynamically significant stenosis

Abstract Introduction Atherosclerotic coronary disease increases morbidity and mortality worldwide. Lipoprotein A (LpA) has emerged as a cardiovascular risk marker, but little is known of its direct influence in plaque volume and composition. Spectral computed tomography (CT) technology allows to characterize coronary plaques with new promising tools. Purpose To evaluate the association of LpA with the extent and composition of non-significant coronary plaques producing stenosis <50%. Methods We prospectively recruited 109 patients referred for noninvasive CT angiography (November 2023-January 2024) with suspected coronary artery disease. 20 had totally/partially non-calcified, non-significant coronary plaques. Plaques were segmented and volume was measured. Their composition was stablished as calcified (>200 UH), lipidic (<60 UH) and fibrous (60-200 UH). Spectral data-based plaque parameters were analyzed, including radiological attenuation on polyenergetic images (CTPI), on virtual low/high monoenergetic images (CT40KeV and CT140KeV, respectively), variation in attenuation across monoenergetic levels (slope40-140 KeV) and Z-effective value. CT scan images were acquired with a 128 detectors dual-layer spectral scan with prospective-retrospective/synchronization. Intravascular iodine-based contrast was administered. LpA was stablished as high (≥25 mg/dL) or low (<25 mg/dL). Results Mean age was 60 ± 11. Cardiovascular risk factor were equally distributed between groups. We analyzed 33 plaques. Total plaque volume was significantly higher in high LpA patients (125.9 mm3 vs 62.1 mm3). There were no differences in plaque composition by LpA (Table). Additionally, spectral data showed significantly higher plaque attenuation on CT140KeV images in high LpA patients (36.07 vs 21.32 HU; p = 0.05). There were no differences for the rest of spectral parameters. Conclusions Plaque volume was higher in patients with non-significant atherosclerotic disease and high LpA, but these plaques showed similar composition in high and low LpA patients. These patients might, therefore, respond to the same conventional treatment event though there is not specific treatment for high LpA yet. Additionally, spectral CT140KeV images could add more precision differentiating these plaques since radiological attenuation in these reconstructions is higher in patients with high LpA.TableFigure

A Case of A Middle-Aged Woman with Cor Triatriatum Dexter and Sick Sinus Syndrome: Comprehensive Cardiovascular Evaluation

This case study discusses a 51-year-old woman with a complex cardiovascular condition, cor triatriatum dexter, complicated by sick sinus syndrome. The patient presented with a history of bradycardia, dizziness, and amaurosis, and was admitted to the emergency department due to numbness in her right limb. Diagnostic examinations, including computed tomography (CT) and cardiac color-ultrasound screening, revealed cor triatriatum dexter along with an enlarged left atrium and ventricle. Additional findings included the absence of the inferior vena cava and polysplenic syndrome. Based on these results, double-chamber pacemaker surgery was recommended, supported by cardiac and thoracic-abdominal CT angiography and three-dimensional vascular reconstruction. This case underscores the importance of comprehensive examinations in identifying associated cardiovascular abnormalities.

Impact of waist circumference and abdominal fat distribution on coronary artery disease severity stratified by computed tomography-derived SYNTAX score

Abstract Background Waist circumference (WC) is the most convenient anthropometric measure of obesity. Recently, abdominal fat distribution (AFD) has been identified as a more important risk factor for coronary artery disease (CAD) than the absolute amount of adipose tissue. However, studies examining the impact of body composition indicators (BCIs) on CAD severity are lacking. The computed tomography (CT)-derived SYNTAX score (CT-SXscore) is a feasible method for grading CAD severity based on coronary CT angiography (CTA) findings. Purpose This study was aimed to evaluate the association between BCI and CAD severity using the CT-SXscore. Methods We enrolled consecutive patients with suspected CAD who underwent CTA using a 320-row multidetector CT scanner between October 2014 and March 2020. Plain abdominal CT was also performed at the umbilical level to measure the visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) areas. The total adipose tissue (TAT) area was calculated as the sum of VAT and SAT. To assess the AFD, the VAT/SAT (V/S) ratios were also calculated as the VAT area divided by the SAT area in each case. WC was measured by tracing the body contour at the umbilical level in CT images. The severity of coronary artery stenosis was assessed using CTA. Significant stenosis was defined as a stenosis diameter of ≥50%. The CT-SXscore was calculated in patients with more than one significant stenoses. Each stenotic lesion was evaluated to calculate the CT-SXscore in the same manner as the invasive coronary angiography assessment. We assessed the effects of BCI [i.e., WC, body mass index (BMI), each adipose tissue area, and V/S ratios] on the CT-SXscores. Results 308 eligible patients (mean age, 70.9 ± 10.6 years; 69.5% males) were evaluated. The median values of WC, BMI, TAT, SAT, VAT, and V/S ratio were 84.8 cm, 23.6 kg/m2, 198.2 cm2, 111.8 cm2, 81.0 cm2, and 0.67, respectively. Although WC showed a significant correlation with BMI, TAT, SAT, and VAT area, no correlation was observed between WC and V/S ratio (Figure1). The CT-SXscore showed no association with WC, BMI, and TAT area; however, it exhibited a weak negative correlation with the SAT area and a weak positive correlation with the VAT area. Additionally, a strong correlation was observed between the CT-SXscore and V/S ratio. In the multivariate regression analysis, WC, BMI, TAT, SAT, and VAT were no longer associated with the CT-SXscore after adjusting for traditional coronary risk factors, whereas the V/S ratio remained as the only independent predictor of CAD severity based on the CT-SXscore (Figure2). Conclusions WC was strongly correlated with other BCIs, except for the V/S ratio; however, it could not be identified as a predictive factor of CAD severity. Among the BCIs, only the V/S ratio was an independent predictor of CAD severity, indicating that the AFD revealed by the V/S ratio may be a more important risk factor for progression of CAD than other BCIs.Figure1Figure2

Real world economic evaluation of CT-FFR in patients with suspected coronary artery disease

Abstract Background Incorporation of CT-derived fractional flow reserve (CT-FFR) enhances the precision of Coronary CT Angiography (CCTA) to detect hemodynamically significant coronary artery disease (CAD). However, the financial consequences remain unclear. Purpose Our objective is to assess the economic implications of CT-FFR in the Dutch Healthcare system. Methods This retrospective, single-center cost effectiveness analysis includes patient data of a previously published study assessing the impact of routine CT-FFR availability on clinical management. We collected medical resource use for both diagnostic and therapeutic cardiovascular care with a follow-up duration of 1 year. Costs of CT-FFR analysis were set at €1000, its current price for Dutch hospitals. Median total costs at were compared using the Wilcoxon rank sum test, including a sensitivity analysis in which cost estimations (without registered maximum tariffs) were increased or decreased with 10%. Results A total of 360 patients, classified as having low to intermediate risk of CAD, were enrolled in the study – 224 in the CCTA group and 136 in the CT-FFR group. In addition to undergoing more (invasive) diagnostic testing and revascularization procedures over the studied period, patients in the CCTA-group had more outpatient clinic consultations (p<0.001), presented more frequently to the emergency department (p=0.035) and spend more nights in the hospital (p=0.11). Median costs were €3.347 (IQR €1.066 – €4.862) in the CCTA-group and €1.436 (IQR €1.362 - €3.943) in the CT-FFR group (p=0.091). Increasing cost estimation with 10% revealed a median of €3.431 in the CCTA-group versus €1.479 in the CT-FFR group (p=0.078), decreasing with 10% showed median costs of €3.263 in the CCTA-group and €1.392 in the CT-FFR group (p=0.118). In our sample, CT-FFR guided care would have been significantly cheaper than CCTA-guided care at or below a market price of €770. Conclusion Despite the significant reduction in additional diagnostic testing and hospital visits in the CT-FFR group, CT-FFR guided care was not cheaper than CCTA-guided care at its current market price of €1.000. Economic cost-effectiveness would have occurred from a price of €770 per analysis. The large difference between medians suggests that the lack of significance might partially be attributed to insufficient power in this relatively small sample size. Additionally, this study did not account for costs associated with loss of productivity and quality of life. However, less additional diagnostic testing, less revascularization procedures and less hospital consultations and admissions leads to reduction in hospital resource consumption and patient burden, which is an important advantage of CT-FFR as the number of referred patients increases yearly.

Impact of coronary CT angiography on the hospital outcome among patients admitted with AMI undergoing revascularization procedures in theUS

Abstract Background Coronary CT angiography (CCTA) is gaining popularity as a diagnostic modality for risk stratification among patients hospitalized with acute myocardial infarction (AMI). However, its impact on the hospital outcomes among this population of patients remains to be determined. Methods Using national inpatient sample database, admission cases with a diagnosis of AMI who underwent revascularization procedures were identified from 2016-2020. The prevalence of CCTA was determined among the patient population and stratified based on the type of AMI (STEMI vs. NSTEMI) and revascularization procedure (PCI vs. CABG). Hospital outcomes were compared among the study strata. Results A total of 862,064 admission cases for STEMI and 3,586,944 admission cases for NSTEMI were identified out of which 661,958 cases underwent revascularization procedures. The utilization of CCTA was roughly 10 times higher among AMI cases undergoing PCI than those undergoing CABG (0.5% vs. 0.06%, p<0.0001). Prior CCTA increased the odds of receiving PCI by 79.3 times and the odds of undergoing CABG by 2.8 times. Among STEMI patients undergoing PCI, prior CCTA was associated with a lower mortality rate and non-home disposition (13.8% vs. 21.2%, p<0.0001) compared to no CCTA (3% vs. 5.5%, p=0.01). For NSTEMI patients undergoing PCI, CCTA was associated with a lower non-home disposition (16.5% vs. 20.6%, p=0.003) but not a significantly lower mortality rate. CCTA did not demonstrate any statistically significant differences for AMI patients undergoing CABG. On the other hand, CCTA increased the cost of hospitalization by $15,130.7 for STEMI patients undergoing PCI, length of stay (9 days) and hospital cost for STEMI patients undergoing CABG ($302,802), and total hospital cost for NSTEMI patients undergoing PCI by $8,705. Conclusions Using CCTA helps in risk stratifying AMI patients for revascularization procedures, allocating PCI to those admitted with STEMI and CABG to those with NSTEMI. Although CCTA reduces the risk of death and non-home disposition among STEMI patients undergoing PCI, it also increases hospital charges for patients receiving revascularization procedures.

Association between lipoprotein particle concentration and size and progression of coronary plaque: the MACS Longitudinal Coronary CT angiography study

Abstract Background People living with HIV have greater risk of cardiovascular diseases (CVD) than people without HIV and tend to have different risk profiles, including higher serum triglycerides and lower LDL cholesterol levels. Nuclear magnetic resonance (NMR) provides a detailed phenotype of lipoproteins. Purpose To examine the associations between lipoprotein particle concentrations and size and progression of coronary artery plaque among people living with and without HIV, and whether these associations differ by HIV serostatus. Methods Men with no clinical CVD in the Multicenter AIDS Cohort Study (MACS) who underwent a coronary CT angiography at baseline (2010-13) and follow-up (2015-17) were included. NMR spectroscopy was completed on fasting serum samples at baseline. Logistic regression models for the change in total coronary plaque volume (in tertiles) were estimated with NMR-derived lipoproteins as predictors. Levels were log-transformed and standardized to make results comparable. Models were adjusted for demographics, statin use and HIV serostatus (model 1) with addition of CVD risk factors (model 2). Interactions by HIV serostatus were also tested. Results A total of 549 men (314 with HIV; 235 without HIV) were included. Mean age was 53 ±7 years; 58% were White, 30% Black, and 12% Hispanic. Coronary plaque was present in 70% and plaque volume progressed in 79% of the cohort. Among men with HIV, 81% had undetectable HIV RNA and 12% had a diagnosis of AIDS at baseline. Men with HIV had significantly higher levels of small LDL-P, and total, medium and large VLDL-P levels compared to men without HIV, and lower levels of total, small and large HDL-P (Table 1). Men with HIV had significantly greater progression of plaque volume (37 mm3) compared to men without HIV (31 mm3, p<0.05). Levels of total and small LDL-P concentrations were directly associated with plaque progression, whereas large HDL-P was inversely associated with plaque progression in the combined sample (Model 2). Associations between total and small LDL-P with plaque progression were stronger in men with HIV than in men without HIV in models 1 and 2 (interaction p<0.01). While associations in fully adjusted models for total VLDL-P and small VLDL-P were significant in men without HIV, there were no significant associations between these particle concentrations with coronary plaque progression among men without HIV (interaction p< 0.01) (Model 2, Table 2). Conclusion Associations between lipid particle concentrations and coronary plaque progression differed between men with and without HIV, with stronger associations seen in men without HIV for total and small LDL-P. Despite having higher VLDL and lower HDL particle concentrations at baseline, these particle concentrations were only associated with plaque progression in men without HIV. Further research is needed to elucidate HIV specific factors for plaque progression to tailor risk reduction strategies.