Coronary Computed Tomography Angiography Research Articles

Coronary Computed Tomography Angiography in Heart Transplant Patients: Current Insights and Future Directions

Cardiac allograft vasculopathy (CAV) remains a significant challenge after heart transplantation, necessitating effective surveillance methods. This review centers around the role of coronary computed tomography angiography (CCTA) in CAV surveillance, given its unique capabilities to visualize and quantify CAV in comparison with other imaging modalities, including invasive coronary angiography and intravascular ultrasound. CCTA has shown good diagnostic performance for detecting and monitoring CAV, exemplified by a higher sensitivity and negative predictive value compared with invasive coronary angiography. Additionally, CCTA can provide valuable functional insights with fractional flow reserve integration. An additional, considerable benefit of CCTA is that it allows for the opportunity to assess other imaging markers of cardiometabolic and general health, including coronary artery calcium score, epicardial fat volume, liver fat, vertebral bone density, and lung density, which allows for a comprehensive assessment of the overall health of the patient.

Supported bridge position in one-stop coronary and craniocervical CT angiography: A randomized clinical trial.

The routine patient arm position differs between coronary CT angiography (CTA) and craniocervical CTA protocols. To investigate the clinical feasibility of supported bridge position (SBP) in combined coronary and craniocervical CTA. Prospective enrollment included patients with suspected coronary artery disease (CAD) or craniocervical artery disease (CCAD) from February 2022 to November 2022. Patients were divided into three groups: coronary or craniocervical CTA according to CAD or CCAD using standard position (group 1), combined CTA with naturally arm-down position (group 2) and SBP (group 3). Statistical analysis of objective image quality, such as noise and contrast-to-noise ratio (CNR), subjective image quality, patient position and radiation dose was performed among the three groups. Two hundred and one patients (median age, 67 years; 138 men) were included. In terms of CNR for cardiac segment, group 1 and group 3 had no statistical difference, both significantly higher than group 2 (group 1, 12.56±2.05; group 2, 10.4±2.43; group 3, 11.94±2.22; P<0.05). Subjective image evaluation revealed no statistically significant differences among the three groups of coronary arteries (P>0.05). Additionally, the lateral project value of scout images at the heart level indicated a significant difference (119.48±12.19, 182.34±25.09, and 140.58±19.68 of patients, for group 1, group 2, and group 3, respectively, P<0.05). No statistical differences were observed in between group 1 and group 3 (cardiac scan, 15.77 [15.07-16.37] mGy vs. 14.88 [12.19-18.81] mGy; craniocervical scan, 7.85 [7.69-8.01] mGy vs. 7.88 [7.88-7.89] mGy; all P>0.05). However, group 2 had a higher dose (19.54 [16.86-22.85] mGy and 10.87 [10.86-10.87] mGy, for cardiac and craniocervical scans, respectively). In comparison with a naturally arm-down position, SBP, which aligns the humerus bones with the spinal column, can provide diagnostic image quality at routine dose level of standard position CTA.

Dynamic CT myocardial perfusion combined with coronary CT angiography for detecting hemodynamical significance of coronary artery stenosis: a comparative study.

This study aimed to evaluate the diagnostic performance of combined dynamic stress CT myocardial perfusion imaging (CTP) and coronary CT angiography (CTA) alongside CT-derived fractional flow reserve (CT-FFR) in detecting hemodynamically significant coronary artery disease (CAD). A total of 33 patients (86 vessels) who underwent coronary CTA, dynamic stress CTP, and coronary angiography were included. Vessels exhibiting 30-90% stenosis were subjected to FFR analysis based on coronary angiography (Angio-FFR). Hemodynamic significance, determined by Angio-FFR ≤ 0.80, and imaging findings were evaluated. The evaluation involved a comparison between the combined use of coronary CTA, CTP and CT-FFR, versus the sole use of coronary CTA. Out of 86 coronary vessels, 17 (19.8%) exhibited hemodynamically significant stenosis. The sensitivity, specificity, and accuracy of coronary CTA for detecting ischemia were 94.12%, 34.78%, and 46.51%, respectively. Adding CTP to CTA improved specificity to 88.41%, and accuracy to 87.21%, respectively. The area under the curve (AUC) for the discrimination of functional significant stenosis was 0.798 when using CTA alone, and for CTA plus CTP, it reached 0.910. Furthermore, the combination of CTA, CTP and CT-FFR, showed accuracy of 88.37%, sensitivity of 88.24% and specificity of 88.41% with the AUC of 0.946. The integration of dynamic CTP with CTA significantly enhances the diagnostic accuracy for identifying patients with hemodynamically significant CAD, compared to the use of CTA alone. This study underscores the value of combining CTP, CT-FFR, and CTA in improving diagnostic precision for CAD. The combination of CTP, CT-FFR and CTA offers a multifaceted assessment for patients with CAD by simultaneously providing anatomical detail, functional analysis, and physiological quantification, which facilitating rapid, accurate, and optimal clinical decision-making and significantly enhances patient management.

Aeromedical Fitness Considerations in Myocardial Bridging: A Case Study and Literature Review

Aims: Management of cardiac disease in aeromedical expertise can be challenging for asymptomatic crew members, especially during the first aeromedical examination, myocardial bridging is a good example. Presentation of Case: A 24-year-old student pilot candidate shows repolarization disorders at the ECG in the aeromedical examination, the exploration allowed the discovery of a myocardial bridge on The Coronary computed tomographic angiography (CCTA) of the left anterior descending (LAD) coronary artery responsible for tight stenosis. Discussion: The prevalence of MB varies according to the method of investigation, ranging from 2% in coronary angiography and 19% in coronary computed tomography to 42% in autopsy.The prevalence among active civilian aircrew (pilots and cabin crew) monitored at CEMPN is 0.4%, all revealed by electrocardiogram abnormalities. MB are usually small and of no clinical significance, the myocardial bridge proximal segment has been associated with atherosclerosis. Symptomatic patients with myocardial bridges as their only cardiac abnormality may present with myocardial ischemia, acute coronary syndromes, coronary spasm, syncope or even sudden death. The initial therapeutic strategy in the treatment of MB is medical management. Revascularization is indicated by PCI or surgery, including coronary artery bypass grafting (CABG) or myotomy in the case of symptoms recalcitrant to maximal medical treatment. The aviation environment may expose aircrew to additional physiological stressors, including hypobaria, hypoxia and sustained acceleration (+Gz). Such exposure may present a risk if associated with cardiovascular abnormalities, potentially leading to incapacity to fly due to symptoms or complications of the myocardial bridge. Conclusion: The myocardial bridge is an anatomical variant rather than a congenital anomaly with varied symptomatology (ECG abnormality, stable or unstable angina or sudden death), the aeromedical decision is made on a case-by-case basis, and makes a challenge diagnostic, particularly for asymptomatic crews.

Management of acute chest pain in the Emergency Department: benefits of coronary computed tomography angiography.

Acute chest pain (ACP) is a frequent cause of Emergency Department (ED) admissions, with millions of cases reported globally each year. Timely and accurate diagnosis is crucial due to the wide range of underlying causes, such as acute coronary syndrome (ACS), pulmonary embolism (PE), aortic dissection, and others. Misdiagnosis can lead to missed life-saving interventions or, alternatively, unnecessary hospitalizations, escalating healthcare costs. While risk stratification tools like the HEART, GRACE, and TIMI scores are useful, additional imaging is often required to achieve diagnostic precision. Coronary computed tomography angiography (CCTA) has shown significant potential in enhancing diagnostic accuracy and improving patient outcomes. In this review, we explore the challenges physicians encounter when evaluating ACP in the ED, emphasizing the utility of CCTA as a key diagnostic tool. Additionally, we present a clinical case that illustrates how CT scan effectively aids in diagnosing patients with ambiguous symptoms, with CT imaging playing a pivotal role in identifying the underlying pathology.

Abstract 4135655: Gender Differences in Invasive Angiography and Early Revascularization after Coronary Computed Tomography Angiography

Background: Coronary CT angiography (CCTA) has emerged as a first line tool for detecting CAD and assessing need for invasive coronary angiography (ICA). Historically, women have higher cardiovascular mortality compared to men with similar coronary plaque burden, yet remain undertreated. This study aims to investigate gender differences in ICA rates and subsequent revascularization following CCTA. Methods: This study included adults who underwent CCTA between 2013-2019 at a single institution. CCTA stenosis severity was categorized as &lt;50%, 50-69% and ≥70%. Plaque burden was assessed by segment involvement score (SIS), defined as number of coronary segments with plaque. Outcomes included ICA and revascularization within 90 days of CCTA. Multivariable logistic regression analysis was performed after adjustment for demographic, clinical, and imaging variables. Results: Of 5,855 patients (mean age 61 years, 58% men) who underwent CCTA, 582 (9.9%) and 386 (6.6%) underwent ICA and revascularization, respectively. There was no significant difference in ICA rates between men and women with similar CCTA stenosis severity ( Figure 1A ; stenosis 50-69%: 17.9% vs. 19.2%, p=0.677; stenosis ≥70%: 53.8% vs. 58.3%: p=0.313). However, among patients with stenosis ≥70% who underwent ICA, men had significantly higher rates of revascularization ( Figure 1A . 80.1% vs. 69.2%, p=0.029). In multivariable analysis, male gender was an independent predictor of revascularization after adjustment for clinical characteristics, including CCTA stenosis severity and SIS (male gender: OR 1.58, 95% CI: 1.01-2.47, p=0.047). Of note, in patients with stenosis ≥70%, rates of revascularization in women were significantly lower in the early study period (years 2013-2015, p=0.020); however, the difference narrowed in the recent study period (years 2016-2019, p=0.309) ( Figure 1B) . Conclusion: There were comparable ICA rates between men and women. Women with severe stenosis (≥70%) by CCTA had significantly lower rates of revascularization, particularly in the early study period. These findings suggest a disparity in the management of CCTA-identified severe CAD, though it has demonstrated improvement in recent years.

Abstract 4137782: Fibrinogen-to-Albumin Ratio Does Not Correlate with Comprehensively Assessed Coronary Artery Disease Severity or High-Risk Plaque Features on Coronary Computed Tomographic Angiography

Background: Fibrinogen-to-albumin ratio (FAR) has been proposed as a readily available inflammatory biomarker associated with coronary artery disease (CAD). However, its association with CAD severity and prognosis has predominantly been assessed in patients with acute coronary syndromes (ACS). The Leiden score is a validated comprehensive measure of CAD incorporating stenosis proximity, severity, and plaque type that independently predicts cardiovascular events. Whether FAR is associated with Leiden score or high-risk plaque features on coronary computed tomographic angiography (CCTA) in stable outpatients is unknown. Methods: Adult outpatients undergoing clinically indicated CCTA were enrolled (5/2021-9/2023) in a prospective study assessing the relationship of plaque to immune markers and provided same-day pre-scan peripheral venous blood samples. CCTAs were post-processed and analyzed by the consensus of two expert readers blinded to clinical data using a 17-segment model to determine coronary artery calcium (CAC), Leiden score, and high-risk plaque features. Patients were grouped by FAR (quartiles), Leiden score (&lt;5, 5-20, &gt;20), and CAC score (0, &gt;0-100, &gt;100-300, &gt;300-1000, &gt;1000). Numerical variables were compared via Wilcoxon and Kruskal-Willis tests. Spearman correlation was calculated between FAR and Leiden score. Results: Of 284 patients, 53.8% were male, 86.7% were white, and 58.8% were on a statin (Table 1). Median FAR was 70.3 mg/g, 64.0% had a non-zero CAC score, and 25.0% had at least one segment with one high-risk plaque feature. Across quartiles of FAR, there was no difference in Leiden score (5.8 (IQR: 0.0-18.5), 12.4 (3.1-20.7), 8.0 (0.0-19.9), 6.8 (0.0-21.1), p=0.50) or probability of having at least one segment with at least one (29.6%, 23.9%, 23.9%, 22.5%, p=0.69) or two (18.3%, 14.1%, 12.7%, 15.5%, p=0.66) high-risk plaque features. There was no correlation between FAR and Leiden score (R=0.03, p=0.66). There was no difference in FAR when stratified by Leiden score (Table 1, p=0.53), CAC score (Table 2, p=0.50), or number of segments with at least one high-risk plaque feature (Table 3, p=0.18). Conclusion: In a prospective cohort of adult outpatients across a wide spectrum of CAD burden with high rates of baseline statin use, FAR was not associated with CAD or presence of high-risk plaque features on CCTA. Further evaluation of its role as an inflammatory biomarker in larger populations, particularly patients without ACS, is required.

Abstract 4140130: Association of Depression and Anxiety with Coronary Plaque: The Miami Heart Study (MiHeart)

Introduction: The prevalence of psychological disorders have been increasing, especially since the COVID-19 pandemic. Multiple mechanisms such as medication nonadherence, negative coping behaviors, and systemic inflammation may mediate the potential effects of depression and anxiety on atherosclerosis. Question: Is there an association of depression or anxiety with the presence of plaque assessed by coronary computed tomography angiography (CCTA) among adults free of clinical coronary artery disease (CAD)? Aim: We aim to examine the association of psychological factors with CCTA-based plaque, as they may be key targets for prevention and CCTA could be considered for enhanced risk characterization. Methods: This cross-sectional study analyzed baseline data from the community-based Miami Heart Study (MiHeart). Depression was assessed by the Patient Health Questionnaire 8-item scale with a score ≥10 indicating binary depression. Anxiety was assessed by the Generalized Anxiety Disorder 7-item questionnaire with a score ≥10 demonstrating binary anxiety. The outcome was the binary presence of any plaque on CCTA. Multivariable logistic regression models were adjusted for potential confounders and clinically relevant risk factors. Sensitivity analyses further examined the severity of depressive symptoms, severity of anxiety symptoms, individuals with either depression or anxiety, and individuals with both depression and anxiety as predictors of coronary plaque. Results: Of the 2,356 individuals (mean age 53.4±6.8 years), 50.4% were men and 47.1% were of Hispanic ethnicity. Depression and anxiety were reported in 143 (6.1%) and 224 (9.5%) of individuals, respectively. CCTA-identified plaque was present in 49.0% of participants with depression and 54.0% of those with anxiety, and plaque presence did not significantly differ when compared to those without depression or without anxiety, respectively. There were no significant associations between depression and plaque (adjusted odds ratio [aOR]: 1.03; 95%CI [0.70, 1.52]; p=0.891) or between anxiety and plaque (aOR: 1.27; 95%CI [0.93, 1.73]; p=0.138) in all regression models. On sensitivity analysis, there were also no statistically significant associations found. Conclusion: Our study found no association of depression, anxiety, their combination, or their severity with coronary plaque on CCTA in asymptomatic adults. To our knowledge, this is the first large study on this topic utilizing CCTA data in a U.S. population.

Abstract 4137243: Dynamic changes of pericoronary fat attenuation index predicting changes of coronary plaque burden

Background: Percent atheroma volume (PAV) is a validated index of coronary plaque burden, linking to adverse cardiac events. Meanwhile, pericoronary fat attenuation index (FAI) on coronary computed tomography angiography (CCTA) image is a novel prognostic marker of coronary inflammation. Research Questions: It is unknown the impact of coronary inflammation (i.e., FAI) on the progression of coronary PAV in patients at an increased risk of adverse cardiac events. Methods: Patients with type 2 diabetes mellitus (T2DM) who underwent at least two clinically indicated CCTA examinations (time interval &gt; 1 year) at our center were potentially eligible for enrollment. Eligible patients presented with more than one study plaque, defined as non-obstructive stenosis at baseline and not being intervened during serial CCTA. Longitudinal CCTA images were assessed for FAI and compositional plaque characteristics (e.g., PAV) using dedicated post-processing softwares. The relationships between changes in FAI and progression of compositional PAV were examined using the logistic and linear regression analysis. Results: A total of 204 T2DM patients (mean age, 61.2 ± 9.3 years; male, 68.1%) with 366 study plaques were enrolled. All patients were treated with statins, and their time interval between longitudinal CCTAs was 14.1 (12.9, 17.6) months. Compared with patients with improved coronary inflammation (ΔFAI ≤ 0), those with deteriorated coronary inflammation (ΔFAI &gt; 0) had lower high density lipoprotein cholesterol and baseline FAI, whereas higher blood pressure (all p &lt; 0.05). Meanwhile, compared to patients with ΔFAI ≤ 0, those with ΔFAI &gt; 0 had more Δoverall and Δnon-calcified PAV (all p &lt; 0.05). Importantly, these findings were consistent in a dedicated propensity score matching analysis. In logistic regression analysis, ΔFAI &gt; 0 was associated with annual progression of overall PAV and non-calcified PAV, whereas ΔFAI ≤ 0 associated with annual regression of overall PAV and non-calcified PAV after adjusting for cardiac risk factors, baseline PAV and medications (all p &lt; 0.05). Similarly, in linear regression analysis, changes of FAI were independently positively associated with annual changes of overall PAV (β=0.545, p&lt; 0.001) and non-calcified PAV (β=0.461, p&lt; 0.001) (Figure 1). Conclusion: In this longitudinal CCTA study, changes of coronary inflammation are closely correlated with changes of overall and non-calcified PAV among T2DM patients treated with statins.

Abstract 4138517: Role of Coronary Computed Tomographic Angiography in Patients with Discordant Findings on Exercise Stress Echocardiography

Background: Exercise stress echocardiography is routinely used for risk stratification and diagnosis of myocardial ischemia in low-to-intermediate risk patients with suspected coronary artery disease (CAD). Discrepancies between exercise electrocardiography (EKG) and echocardiography (ECHO) are common in clinical practice. Prior literature suggests that patients with discordant stress test results generally have worse outcomes, though the extent of epicardial atherosclerotic disease remains unclear. Coronary computed tomographic angiography (CTA) has gained a class I recommendation for the assessment of atherosclerotic burden per ACC/AHA chest pain guidelines. Using non-invasive fractional flow reserve (CT-FFR), the functional significance of lesions can also be assessed. This study investigates the incidence and burden of CAD in patients with discordant exercise echocardiography findings. Methods: Patients aged 18 or older who had exercise echocardiography followed by CTA from January 1, 2013, to January 31, 2023, were retrospectively enrolled in this study and categorized into two discordant result groups: EKG+/ECHO- or EKG-/ECHO+. Those who failed to achieve the target heart rate or had a paced rhythm/left bundle branch block on baseline EKG were excluded. CTA findings were classified as no CAD, non-obstructive CAD (&lt;50% stenosis), obstructive CAD (≥50% stenosis), and obstructive CAD with FFR+ (&lt;0.75). Results: The study included 198 patients, the majority female (56.0%), with a mean age of 61 ±10 years. Among them, 159 (80.3%) were EKG+/ECHO- and 39 (19.7%) were EKG-/ECHO+ (Table 1). In the EKG+/ECHO- group, 55 (34.6%) had no CAD, 48 (30.2%) had non-obstructive CAD, and 56 (35.2%) had obstructive CAD, out of which 19 (33.9%) were FFR+. In the EKG-/ECHO+ group, 13 (33.3%) had no CAD, 17 (43.6%) had non-obstructive CAD, and 9 (23.2%) had obstructive CAD of which 3 (33.3%) was FFR+. There was no statistically significant difference in the degree of CAD between the two cohorts. Conclusions: The majority of patients with discordant results on exercise echocardiography were found to have CAD. There was no significant difference in the degree of disease between the EKG+/ECHO- or EKG-/ECHO+ groups. Overall, discordant results on exercise echocardiography should not be discounted and warrant further evaluation. CTA provides important information that can impact the diagnosis and further medical management of patients with chest pain and suspected CAD.

Highly inflamed coronary plaque detected by Angio-CT in a 28-year-old patient with STEMI and long COVID-19

AbstractLong COVID-19 syndrome increases the risk of cardiovascular events. Although rare in young people, acute coronary syndromes occur more often in those recently infected with COVID-19. This report discusses a rare case of myocardial infarction in a 28-year-old male with no prior medical issues, occurring four weeks after a mild COVID-19. Initially, the patient refused invasive coronary angiography, so a coronary computed tomography angiography (CCTA) was conducted during an ST-elevation myocardial infarction (STEMI). The CCTA, using fat attenuation index (FAI) technology, revealed significant inflammation at the culprit lesion. This CCTA and FAI analysis were done shortly after the STEMI onset, before revascularization, highlighting the case's uniqueness. In patients with recent COVID-19, CCTA combined with FAI analysis of perivascular inflammation can help identify those at risk for acute coronary events. In this case, FAI analysis detected high inflammation, suggesting a potential cause for STEMI in a young patient with long COVID-19.

Abstract 4144554: Revascularization of Patients with Low-Density Non-Calcified Plaque was Associated with Lower Occurrence of Acute Coronary Syndrome

INTRODUCTION: Coronary CT angiography (CCTA) is a powerful noninvasive tool for identifying high-risk plaque, such as low-density non-calcified plaque (LD-NCP). Though, the optimal treatment of patients with LD-NCP remains unclear. This study explored the association of revascularization in the setting of LD-NCP with the occurrence of acute coronary syndrome (ACS). Methods: This was a post-hoc analysis of the ICONIC study. A subset of 234 patients that underwent CCTA with subsequent ACS were matched to 234 control patients who also underwent CCTA but did not have ACS during follow-up. Patients were also followed for occurrence of revascularization, either coronary artery bypass graft or percutaneous coronary intervention. Atherosclerosis imaging-enabled quantitative CT (AI-QCT) was used to measure diameter stenosis, and LD-NCP, non-calcified plaque, and calcified plaque volumes from each CCTA. LD-NCP was defined as plaque with -190 to 30 Hounsfield Units. Patients were stratified based on the presence of LD-NCP. Subgroup analysis was conducted to compare the occurrence of ACS with the rate of revascularization. Kaplan-Meier survival curves and extended Cox regression analysis were used to evaluate the effect size of revascularization and LD-NCP on occurrence of ACS. Results: AI-QCT was completed in 448/468 subjects (follow-up time [MEAN±SD] 2.44±2.48 years). The median of LD-NCP was 1.2 mm 3 for patients with &gt;0 mm 3 LD-NCP. There were 85 patients with LD-NCP &gt;1.2 mm 3 and 363 patients with LD-NCP ≤1.2 mm 3 . In patients with LD-NCP &gt;1.2 mm 3 , the rate of revascularization in patients with and without ACS was 3/52 (5.8%) versus 14/33 (42.4%) (p&lt;0.001). In patients with LD-NCP ≤1.2 mm 3 , the rate of revascularization in patients with and without ACS was 36/170 (21.2%) versus 39/193 (20.2%) (p=0.897). In comparison to patients without revascularization and LD-NCP ≤1.2 mm 3 , patients with LD-NCP &gt;1.2 mm 3 and revascularization were less likely to have ACS during follow-up (adjusted HR: 0.20 [0.07, 0.61]; p=0.005). Additionally, patients with LD-NCP &gt;1.2 mm 3 who did not undergo revascularization were more likely to have ACS (adjusted HR: 1.47 [1.03, 2.12]; p=0.036). Hazard ratios were adjusted for diameter stenosis, and non-calcified and calcified plaque volume. Time-dependent coefficients were included for diameter stenosis. Conclusion: Revascularization of patients with LD-NCP &gt;1.2 mm 3 identified on CCTA with AI-QCT was associated with less risk for ACS.

Abstract 4120670: Pericoronary Adipose Tissue Inflammation as a Marker of Increased Coronary Plaque Burden in Patients With Chronic Coronary Artery Disease With Zero Calcium Score

Background: Dysfunctional or excess adiposity plays pivotal role in the development of coronary atherosclerosis. It remains unclear whether pericoroanry adipose tissue (PCAT) inflammation is associated with increased coronary plaque burden in its early stage of atherosclerosis, independent of traditional coronary risks or cardiovascular-kidney metabolic health. Purpose: To investigate the association of PCAT inflammation with coronary plaque burden in patients with newly suspected with chronic coronary artery disease (CAD) and zero calcium score who underwent coronary computed tomography angiography (CCTA). Methods: This retrospective CCTA study consists of 294 chronic CAD patients with zero calcium score (59 years, male 51 %). Chronic CAD was defined as stable condition with presence of increased non-calcified plaque burden on CCTA (Figure 1A-D). PCAT attenuation (PCATA) was assessed by fat attenuation index in the major three coronary arteries (right coronary artery, RCA; left anterior descending artery; LAD, and left circumflex coronary artery, LCX)(Figure 1C and D). Multivariable analysis using linear regression model was performed to determine independent predictors of increased %PV by adjusting for traditional coronary risks, metabolic risks, and chronic kidney disease (CKD). Hisayama Risk Score (HRS) was calculated to estimate 10-year cardiovascular risks. Results: Mean %plaque volume (PV) and PCATA-RCA was 44±4.0％ and -77±8.8 HU. %PV was correlated with age (p&lt;0.05), systolic blood pressure (p&lt;0.05), non-HDL cholesterol (p&lt;0.05), Hisayama risk score (p&lt;0.05, Figure 2), PCATA-RCA (p&lt;0.001, Figure 3), PCATA-LAD (p&lt;0.001), and LCX-PCATA (p&lt;0.001). In a multivariable linear regression model adjusting for age, sex, hypertension, diabetes, dyslipidemia, and current smoking (model 1), PCATA-RCA was independently associated with %PV [beta, 0.17; 95% confidential interval (CI) 0.115-0.217, p &lt; 0.001]. In a model adjusting for age, sex, metabolic syndrome, body mass index ≥23kg/mm 2 , and CKD (model 2), PCATA-RCA (beta, 0.18; 95% CI 0.128-0.232, p&lt;0.001) and high-risk HRS (beta, 3.1; 95% CI 1.35−4.87, p&lt;0.001) were independently associated with %PV. Similarly, independent associations of PCATA in LAD and LCX with %PV was observed. Conclusion: This study demonstrates that PCATA is a robust marker related to increased burden of coronary atherosclerosis even in the early stage of atherosclerosis as defined by zero coronary artery calcium score.

Abstract 4138602: Effect of Left Ventricular Ejection Fraction On Computed Tomography-Derived Fractional Flow Reserve Diagnostic Accuracy For Significant Coronary Artery Disease

Background: Coronary Computed Tomography Angiography (CCTA) and CT-derived fractional flow reserve (CT-FFR) accurately assess the severity of coronary artery disease. However, the diagnostic accuracy of CT-FFR in patients with low left ventricular ejection fraction (LVEF) is unknown. Goal: Describe the per-vessel diagnostic performance of CT-FFR to detect significant coronary disease in patients with normal and reduced LVEF by echocardiogram. Methods: This was a retrospective study of 441 patients who underwent CCTA and CT-FFR at the UMass Memorial Health System between 2020 and 2023. Those with echocardiogram and invasive coronary angiography were analyzed and divided in two groups based on two-dimensional LVEF: those with LVEF &lt; 55%, and with LVEF ≥ 55%. We excluded those with prior coronary stents, incomplete CCTA, CT-FFR data due to artifacts, or poor-quality echocardiographic images. CT-FFR ≤ 0.8 was considered abnormal. Significant coronary disease by invasive angiography (reference standard) was defined as lumen stenosis ≥ 70% (left main ≥ 50%), or abnormal physiologic characteristics by FFR, resting full-cycle ratio, or instantaneous wave-free ratio. Results: 222 coronary vessels (102 patients) were analyzed. Of 102 vessels (44%) with significant coronary artery disease, 55 (53.9%) were treated with percutaneous coronary intervention, and 25 (24.5%) with coronary artery bypass grafting. Overall, CT-FFR sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 86.7% (95%CI 78.3-92.7), 75.0% (95%CI 66.4-82.3), 73.2% (95%CI 66.6-78.9), 87.7% (95%CI 81.0-92.3), and 80.1% (95%CI 74.3-85.2), respectively. 37 vessels corresponded to patients with LVEF &lt; 55%, and 185 to those with LVEF ≥ 55%. Diagnostic accuracy in both groups is seen in table 1. Conclusions: Low-normal and reduced LVEF adversely affects the diagnostic performance of CT-FFR, by reducing sensitivity, and slightly increasing specificity.

Microvascular resistance reserve in relation to total and vessel-specific atherosclerotic burden.

The relationship between coronary artery atherosclerosis and microvascular resistance remains unclear. This study aims to clarify the relationship between total atherosclerotic and vessel-specific atherosclerotic burden and microvascular resistance reserve (MRR). In this post-hoc analysis of the PACIFIC 1 trial, symptomatic patients without prior coronary artery disease (CAD) underwent [15O]H2O positron emission tomography, coronary computed tomography angiography (CCTA) and invasive fractional flow reserve (FFR). MRR was assessed across all three coronary branches, utilizing PET-derived coronary flow reserve and invasive FFR measurements. CCTA was used to assess patient and vessel-specific plaque volumes. Percentage atheroma volume (PAV) was defined as total plaque volume divided by vessel volume. The study included 142 patients (55% male, 57.5±8.6 years) with 426 vessels with a mean MRR of 3.77±1.64. While a significantly higher PAV was observed in the left anterior descending artery territory, MRR was similar across the three coronary branches. Generalized Estimating Equations without correction for cardiovascular risk factors identified that patient-specific PAV tertiles but not vessel-specific PAV tertiles were related to vessel-specific MRR. After correction for cardiovascular risk factors, compared to the first tertile of patient-specific PAV, the second tertile showed a vessel-specific MRR decrease of β=-0.362, p=0.018, and the third tertile showed a decrease of β=-0.347, p=0.024. In patients without prior CAD, patient-specific plaque burden was negatively associated to vessel-specific MRR; however, vessel-specific plaque burden was not related to vessel-specific MRR. Our findings suggest that the relation between atherosclerotic burden and an impaired microcirculatory function is of systemic origin.

Plaque characterization and individualized risk assessment

Risk assessment and accurate plaque characterization are key to individual prognosis in coronary artery disease (CAD). The standard of care is cardiac computed tomography (CT), including calcium scoring and coronary CT angiography (CCTA). Diagnosis is based on the CAD-RADS (Coronary Artery Disease-Reporting and Data System) classification. New developments include CT-based fractional flow reserve (CT-FFR) and plaque quantification ("virtual histology"). Acalcium score of0 indicates an event risk of less than 1% over 10years [7, 17]. CAD-RADS classes1 to5 allow risk assessment compared to patients without coronary plaques [2]. CT-FFR has high accuracy (area under the curve [AUC] 0.90; 95% confidence interval 0.87-0.94) in assessing the hemodynamic significance of stenoses compared with invasive coronary angiography [25]. Plaque quantification has shown that anecrotic core greater than 4% is associated with an almost fivefold increase in 5‑year event risk [29]. The presence of obstructive CAD (stenosis > 50%) is astrong prognostic factor. The evaluation of the hemodynamic relevance of 40-90% stenoses by CT-FFR or other functional tests is already guideline-compliant in the USA, but not yet in Germany. Quantitative approaches to measure plaque volume and composition are gaining importance in research and are expected to become relevant in clinical practice. The CAD-RADS 2.0 classification, which also provides therapy recommendations, should be used to assess the extent of CAD.

Abstract 4141498: Coronary Atherosclerosis and Prostate Cancer: The Impact of Androgen Deprivation Therapy

Background: Men with prostate cancer (PC) who receive androgen-deprivation therapy (ADT), targeting the gonadotropin releasing hormone (GNRH) axis, are at higher risk of cardiovascular disease (CVD). However, the pathophysiology behind ADT cardiotoxicity is unclear. Hypothesis: We hypothesize that ADT is associated with accelerated atherosclerosis due to GNRH-mediated inflammatory cascade. Aims: To prospectively evaluate coronary plaque progression, using coronary computed tomography angiography (CCTA), in a cohort of PC men treated with versus without ADT. Methods: Sixty-eight men with localized PC receiving radiation (XRT) alone (n=17) or XRT+ADT (n=51) were prospectively enrolled. Patients underwent CCTA, as per clinical protocols , at baseline and 12-month follow-up. Plaque quantification was conducted, blinded to therapy and time-point, using semi-automated software (Coronary analysis research prototype, Siemens Healthineers, Forchheim, Germany), with assessment of total plaque volume (TPV) and plaque volume by subtype (calcified, CPV, high-density non-calcified, HD, low-density non-calcified, LD) on a per-patient basis. CAD-RADS was also evaluated. Results: At baseline, median (IQR) TPV, CPV, HD, LD (mm 3 ) and CAD-RADS among patients who received XRT alone versus XRT+ADT were 341.1 (118.5-778.2) vs 717.3 (207-1158.9), 22.2 (4.9-131.9) vs 74.3 (21.3-205.8), 306.6 (102.1-593.6) vs 585.8 (175-895.2), 14 (2.3-47) vs 22.6 (6.2-50.4), 1 (1-2) vs 2 (2-3), respectively. At 12-month follow-up, TPV, CPV, HD, LD, and CAD-RADS between XRT alone versus XRT+ADT were 410.1 (177-941) vs 904.6 (283.7-1402), 21 (12.1-195.1) vs 102.6 (30.5-259.4), 372.6 (157.6-721.6) vs 686.1 (242.7-1062.7), 11.7 (5.6-69.8) vs 34 (10.4-62.1), 2 (1-2) vs 3 (2-3). A statistically significant difference between baseline and follow-up was noted among patients treated with XRT+ADT for TPV, CPV, LD (p&lt;0.001), and HD (p=0.006). A significant difference in CAD-RADS grade was noted in both cohorts (p=0.025 for XRT and p&lt;0.001 for the XRT +ADT). There was no significant difference in any plaque volume between baseline and follow-up in the XRT alone cohort. Conclusion: Addition of ADT to XRT for localized PC treatment was associated with a significant progression of TPV, CPV, HD, LD, and CAD-RADS grade over a 12-month period. Insights on ADT cardiotoxicity may lead to enhanced cardioprotective strategies tailored to patients with PC undergoing combined therapy, potentially improving cardiac outcomes.

Abstract 4122389: Accumulation of Epicardial Adipose Tissue as a Marker of Diastolic Dysfunction in Patients With Preserved Left Ventricular Ejection Fraction Undergoing Coronary Computed Tomography Angiograph

Background: Left ventricular diastolic dysfunction (LVDD) plays a major role in the pathophysiology of progression to heart failure with preserved left ventricular (LV) ejection fraction (EF). Although epicardial adipose tissue (EAT) is attracting attention for the underlying pathophysiology, whether increased EAT and coronary plaque burden are associated with LVDD is unclear in patients with chronic coronary artery disease (CAD) and preserved LVEF. Aims: To investigate the association between LVDD and EAT accumulation in chronic CAD patients with preserved LVEF. Methods: We included three hundred fourteen chronic CAD and preserved LVEF patients without history of heart failure (mean age: 66±13 years; 48% female). Thoracic tissue doppler echocardiography (TTDE) analysis included LVDD parameters, including left atrial volume index (LAVI), e’, E/e’ and tricuspid regurgitation (TR) velocity. LVDD was defined according to the American Society of Echocardiography guidelines. Coronary computed tomographic angiography (CCTA) analysis included EAT volume index (EAVi), coronary artery calcium score (CACS), and coronary plaque volume (%PV). Patients were divided into three groups according to EAVi: Group A as normal (&lt;68.1 ml/m 2 , n=127), group B as low (68.1-89.4 ml/m 2 , n=95), and group C as high EATVi (&gt;89.4 ml/m 2 , n=92). Multivariable logistic regression analysis was performed to investigate the association between the clinical parameters, TTDE and CCTA findings, and the presence of LVDD. Results: Compared with Group A, group C was older and more frequently suffered from renal dysfunction. Among the three groups, we observed significant differences in LV mass index, e’, E/e’, and CACS. The EAVi correlated with each LVDD diagnostic component, including e’, E/e’, left atrial volume index (all p&lt;0.05), except for tricuspid regurgitation velocity. A multivariate model showed that age [odds ratio (OR), 1.13; 95% CI, 1.06-1.20; p&lt;0.001] and EAVi (OR, 1.03; 95%CI, 1.01-1.04; p&lt;0.05) were independently associated with LVDD, even after adjusting for LV mass index (OR, 1.1; p &lt; 0.05). There was no independent association of CACS or %PV with LVDD (Table). Conclusion: This study demonstrates that accumulation of EAT and LV mass index but not plaque volume were independent predictors of LVDD in chronic CAD patients with preserved LVEF. Further study is needed to investigate whether EAT predicts the development to heart failure in this population.

Abstract 4135636: Age- and Sex-Related Coronary Atherosclerosis by Artificial Intelligence Quantitative Coronary CT Angiography from the INVICTUS Registry

Background: Coronary plaque analysis using artificial intelligence quantitative coronary CT (AI-QCT) is a promising tool to identify coronary atherosclerosis. However, there is insufficient data on coronary atherosclerosis volume and morphology using AI-QCT in patients who are at high risk of atherosclerosis. The purpose of this study is to clarify the differences in the volume and phenotypes of coronary atherosclerosis by age and gender using AI-QCT. Methods: The INVICTUS Registry is a multi-center registry enrolling patients who clinically underwent coronary CT angiography and invasive coronary angiography with invasive imaging modalities in Japan. Patients with a history of percutaneous coronary intervention or coronary artery bypass graft were excluded in this study. Using AI-QCT, the volume, and phenotypes (calcified, non-calcified, low-density non-calcified plaque [LD-NCP]) of coronary atherosclerosis were analyzed and assessed by age (&lt;55, 55-64, 65-74, and 75 and older) and gender. Results: A total of 982 patients were enrolled in the study. The mean age was 70.3 ± 10.8 years, 71.9% were male. Approximately two-thirds of patients had hypertension (73.3%) and dyslipidemia (71.5%), and 36.7% had diabetes. Mean total plaque volume (PV), calcified PV, non-calcified PV, and low-density PV were 745.5±529.8 mm 3 , 248.3±302.0 mm 3 , 482.2±340.6 mm 3 , and 15.0±29.4 mm 3 , respectively. The results of plaque volume and phenotypes by age are shown in the figure. Compared to those under 55 years of age, total PV increased gradually and significantly by about 10% for every 10 years of age (p=0.022). Though no significant difference was observed in non-calcified PV between the age groups (p=0.379), calcified PV progressively and significantly increases approximately 70% for every 10 years of age (p&lt;0.001). In contrast, the low-density plaque volume showed a trend toward a significant decrease with increasing age (p=0.073). These trends did not differ by gender. Conclusion: In a large cohort of patients at high risk for atherosclerosis analyzed by AI-QCT, total coronary PV increased with age, primarily calcified PV. While no change in non-calcified PV between the age groups, LD-NCPV was likely to decrease with increasing age. These findings may contribute to the guidance for the prevention of coronary artery diseases based on coronary atherosclerosis phenotype by age and gender.

Abstract 4145822: The Enigma of Chest Pain: Rare Presentation of ALCAPA Syndrome in a Young Adult

Introduction: Anomalous Left Coronary Artery Arising from the Pulmonary Artery (ALCAPA), also known as Bland-White-Garland syndrome, is a rare congenital anomaly(incidence:1 in 300,000 live births) typically presenting during infancy. Adult presentations are even rarer due to a high mortality rate of nearly 90% in the first year of life without surgical intervention. This report examines an adult patient with exercise-induced chest pain who received a delayed diagnosis of ALCAPA via multimodal imaging. Case Summary: A 21-year-old male presented to the emergency department(ED) with severe retrosternal chest pain radiating to both shoulders and arms, which began during exercise 30 minutes prior. He had a history of similar, milder episodes during exercise, previously treated as musculoskeletal pain and gastroesophageal reflux disease in the ED. His medical, social, and family histories were unremarkable. Physical examination revealed a soft, continuous murmur along the left sternal border. During this visit, An EKG done showed sinus tachycardia at 110 bpm and deep T-wave inversions in the anterolateral leads, a dynamic ST-T changes from his baseline.Serial Cardiac biomarkers and a lipid profile were within normal ranges. Initially managed for acute coronary syndrome-unstable angina with antithrombotic therapy, beta-blockers, and nitrates, he underwent urgent coronary angiography. This revealed a dilated right coronary artery (RCA) with retrograde flow to the left coronary artery (LCA) into the main pulmonary artery (PA) via collaterals, with no evidence of atherosclerosis (Figure 1).Echocardiography (Figure 2) and coronary CT angiography (Figure 3) confirmed the diagnosis of ALCAPA. The patient underwent successful surgical repair with aortic reimplantation of the LCA and was discharged in good health. Discussion: In adult ALCAPA patients, good collateral circulation may develop; however, myocardial ischemia can occur due to the "coronary steal phenomenon" and poor collateral flow regulation, leading to angina, arrhythmias, and sudden cardiac death. ALCAPA should be considered a differential diagnosis in adults presenting with exercise intolerance, as most sudden cardiac death cases occur by the fourth decade. A high index of clinical suspicion and a multimodality imaging approach is essential for the early diagnosis of this rare coronary anomaly, underscoring the critical role of early surgical intervention in preventing catastrophic, life-threatening events.