Nonobstructive Lesions Research Articles

Automated knowledge‐based detection of nonobstructive and obstructive arterial lesions from coronary CT angiography

Visual analysis of three-dimensional (3D) coronary computed tomography angiography (CCTA) remains challenging due to large number of image slices and tortuous character of the vessels. The authors aimed to develop a robust, automated algorithm for unsupervised computer detection of coronary artery lesions. The authors' knowledge-based algorithm consists of centerline extraction, vessel classification, vessel linearization, lumen segmentation with scan-specific lumen attenuation ranges, and lesion location detection. Presence and location of lesions are identified using a multi-pass algorithm which considers expected or "normal" vessel tapering and luminal stenosis from the segmented vessel. Expected luminal diameter is derived from the scan by automated piecewise least squares line fitting over proximal and mid segments (67%) of the coronary artery considering the locations of the small branches attached to the main coronary arteries. The authors applied this algorithm to 42 CCTA patient datasets, acquired with dual-source CT, where 21 datasets had 45 lesions with stenosis ≥ 25%. The reference standard was provided by visual and quantitative identification of lesions with any stenosis ≥ 25% by three expert readers using consensus reading. The authors algorithm identified 42 lesions (93%) confirmed by the expert readers. There were 46 additional lesions detected; 23 out of 39 (59%) of these were less-stenosed lesions. When the artery was divided into 15 coronary segments according to standard cardiology reporting guidelines, per-segment basis, sensitivity was 93% and per-segment specificity was 81% using 10-fold cross-validation. The authors' algorithm shows promising results in the detection of both obstructive and nonobstructive CCTA lesions.

Nonobstructive coronary disease leading to STEMI

Nonobstructive coronary atherosclerotic lesions can lead to ST-elevation myocardial infarction (STEMI). Thrombus aspiration during a primary percutaneous coronary intervention provides a setting to evaluate the degree of stenosis of culprit lesions leading to STEMI. The aim of this study was to assess the degree of culprit lesion residual stenosis after thrombus aspiration and to compare the demographic, clinical, and angiographic characteristics between patients with obstructive versus nonobstructive residual stenosis. From a single-center registry of 483 consecutive patients with STEMI undergoing a primary percutaneous coronary intervention, 172 patients underwent thrombus aspiration and were eligible for our study. We defined two groups according to the residual stenosis after thrombus aspiration: group A (n=119, 69%) with residual stenosis greater than or equal to 50%, and group B (n=53, 31%) with residual stenosis less than 50%.In terms of the baseline angiographic characteristics, patients with residual stenosis less than 50% had significantly lower prevalence of multivessel disease (15.1 vs. 46.2%, P<0.001). On multivariable analysis of the preprocedural variables, absence of vascular disease (odds ratio 4.99, 95% confidence interval 1.08-23.12, P=0.040) and age less than 59 years (odds ratio 2.67, 95% confidence interval 1.25-5.73, P=0.011) were independent predictors of culprit residual stenosis less than 50%. In this population, a significant proportion of patients with STEMI had nonobstructive residual stenosis after thrombus aspiration. These patients were younger, had a lower prevalence of vascular disease in other vascular territories, and less multivessel disease, suggesting an earlier stage of atherosclerosis.

Prognostic Implications of Nonobstructive Coronary Artery Disease in Patients Undergoing Coronary Computed Tomographic Angiography for Acute Chest Pain

Coronary computed tomographic angiography can detect nonobstructive atherosclerotic lesions that would not otherwise have been detected with functional cardiac imaging. Currently, limited data exist regarding the clinical significance of these lesions in patients with acute chest pain. The aim of our study was to examine the prognostic significance of these nonobstructive findings in a patient population presenting with acute chest pain. We evaluated 959 consecutive patients who underwent coronary computed tomographic angiography for investigation of acute chest pain. The patients were classified as having normal (n = 545), nonobstructive coronary artery disease (CAD; defined as any narrowing <50% diameter stenosis; n = 312), or obstructive CAD (narrowing of ≥50% diameter stenosis; n = 65). Follow-up data for a minimum of 12 months (mean 27 ± 11) was obtained for any major adverse coronary events consisting of death, nonfatal acute coronary syndrome, and coronary revascularization. Compared to patients with normal coronary arteries, those with nonobstructive CAD were older and had a greater prevalence of CAD risk factors. The incidence of major adverse coronary events was equally low among both these groups (0.6% vs 1.3%, for the normal and nonobstructive groups, respectively, p = 0.2). In conclusion, patients with either nonobstructive CAD or normal findings, as evaluated by coronary computed tomographic angiography, for acute chest pain during an intermediate-term follow-up period had equally benign clinical outcomes.

High-frequency QRS analysis improves the specificity of exercise ECG testing in women referred for angiography

BackgroundExercise ECG testing in women for the diagnosis of coronary artery disease (CAD) has a higher false-positive rate compared to men. Consequently, women referred for coronary angiography following a positive exercise test often have normal coronary arteries or non-obstructive lesions. Analysis of the high-frequency components of the QRS complexes (HFQRS) has been reported to provide a sensitive means of detecting myocardial ischemia, independent of gender. The aim of the present study was to prospectively test the diagnostic performance of HFQRS and conventional exercise ECG in detecting stress-induced ischemia in women referred for coronary angiography. MethodsThe study included 113 female patients (age 64±9years) referred for non-urgent angiography. Patients performed a symptom-limited treadmill exercise test prior to angiography. High-resolution ECG was acquired during the test and used for both HFQRS and conventional ST-segment analyses. HFQRS diagnosis was determined by computerized analysis, measuring the stress-induced reduction in HFQRS intensity. The diagnostic performance of HFQRS, ST-segment analysis and clinical interpretation of the exercise test were compared, using angiography as a gold standard. ResultsHFQRS provided sensitivity of 70% and specificity of 80% for detection of angiographically significant coronary obstruction (≥70% stenosis in a single vessel or ≥50% in the left main artery). HFQRS was more specific than exercise ECG test (80% vs. 55%, P<.005), as well as more accurate (76% vs. 62%, P<.01). The number of ECG leads with ischemic HFQRS response correlated with the severity of CAD. HFQRS was highly specific (93%) in patients who achieved their age-predicted target heart rate, and retained its diagnostic accuracy in subgroups of patients with resting ECG abnormalities or inconclusive exercise ECG. ConclusionsHFQRS analysis, as an adjunct technology to exercise stress testing, may improve the diagnostic value of the ECG, and reduce the number of unnecessary imaging and invasive procedures.

Plaque sealing and passivation with a mechanical self-expanding low outward force nitinol vShield device for the treatment of IVUS and OCT-derived thin cap fibroatheromas (TCFAs) in native coronary arteries: report of the pilot study vShield Evaluated at Cardiac hospital in Rotterdam for Investigation and Treatment of TCFA (SECRITT)

The aim of the pilot SECRITT trial was to evaluate the safety and feasibility of sealing the high risk IVUS and optical coherence tomography-derived thin cap fibroatheroma (TCFA), with a dedicated nitinol self-expanding vShield device. After screening with angiography, fractional flow reserve (FFR), intravascular ultrasound virtual histology (IVUS-VH) and optical coherence tomography (OCT), 23 patients met enrolment criteria (presence of non-obstructive VH-derived TCFA lesion with thin cap on OCT) and were randomised to vShield (n=13) versus medical therapy (n=10). In the shielded group, baseline percent diameter stenosis was 33.2±13.5%, FFR was 0.93±0.06. At six-month follow-up in shielded patients percent diameter stenosis further decreased to 18.7±16.9% and FFR remained the same 0.93±0.05. Average late loss was 0.24±0.13 mm. Average baseline fibrous cap thickness was 48±12 µm. After shield placement at six-month follow-up neo-cap formation was observed with average cap thickness of 201±168 µm. There were no dissections after shield placement and no plaque ruptures. In addition, mean stent area of 8.76±2.16 mm2 increased to 9.45±2.30 mm2, that is by 9% at six-month follow-up. The number of malapposed struts decreased from 10.7% to 7.6% and the number of uncovered struts at six months was 8.1%. There were no device-related major adverse cardiovascular events (MACE) events at six-month follow-up. High risk plaque passivation and sealing with a vShield self-expanding nitinol device appears feasible and safe. A long-term larger randomised study with streamlined screening criteria is needed to evaluate the efficacy of this approach over medical therapy.

Prognosis of patients with mild–moderate coronary artery stenosis detected by coronary computed tomography angiography

In addition to the diagnostic performance, coronary computed tomography angiography (CTA) can give important data regarding the prognosis of coronary artery disease (CAD). In this study we aimed to evaluate the prognostic role of coronary CTA in patients with suspected CAD and mild-moderate coronary stenosis. A total of 1115 patients (602 male, 54%; age 58.4 ± 11.4) without previous CAD were enrolled. Patients underwent coronary CTA imaging using dual-source 64-slice CT scanner. For categorization of the coronary atherosclerotic plaques (CAP), the coronary system was divided into 16 separate segments. For each segment, CAPs were categorized as: calcified, noncalcified and mixed. During follow-up of 29.7 ± 13.2 months, cardiovascular events defined as ST segment elevation myocardial infarction (4 patients), non-ST segment elevation myocardial infarction (5 patients) and unstable angina pectoris (20 patients) requiring revascularization or hospital admission were recorded. Cox hazard regression analysis revealed an association between the severity of luminal stenosis (HR: 4.73, 95% CI: 1.36-16.47, p<0.05) and extent (HR: 1.10, 95% CI: 1.00-1.22, p=0.051) and the adverse coronary events in the follow-up. Multivariate Cox hazard regression analysis revealed that nonobstructive (≤ 50%) lesions were the only factor causing increased probability of coronary events in the follow-up (HR: 4.77, 95% CI: 1.36-16.74, p<0.05). The presence and severity of luminal stenosis shown by coronary CTA were associated with prognosis of coronary events in the follow-up. These results may improve the risk stratification in patients evaluated by coronary CTA and provide strategies for the individualized prevention programs.

Correlation Between Red Cell Distribution Width and Coronary Ectasia in the Acute Myocardial Infarction

We read with a great interest the article entitled as ‘‘Assessment of red cell distribution width (RDW) in patients with coronary artery ectasia’’ by Dogdu et al that was published online in August 2011 issue of this journal. The authors clearly demonstrated the elevated level of RDW in the isolated coronary ectasia (CE). The RDW is found to be an independent prognostic factor for cardiovascular outcomes and all-cause mortality, even adjustment for multiple potential confounders including anemia. Increased level of RDW reflects chronic inflammatory state which is also revealing in the pathophysiologic mechanism of the CE. In the acute myocardial infarction (AMI), inflammatory markers usually make peak level that may reflect the accelerated inflammatory process. In such a condition, association between RDW and CE was not investigated before. In addition to the results presented by Dogdu et al, we searched the correlation of RDW and CE in the patients with ST-elevation AMI, and we evaluated whether the correlation between RDW and isolated CE is still valid in the patients with AMI. A total of 201 patients with an ST-elevation AMI were evaluated retrospectively. Upon admission, RDW was measured by the automated hematology analyzers Sysmex XT-1800i (Roche Diagnostic, Istanbul, Turkey). The patients’ angiographic data were evaluated from catheter laboratory records and CE was documented for each patients. Coronary ectasia was defined as a localized or diffuse nonobstructive lesion of the epicardial coronary arteries with a luminal dilation exceeding 1.5-fold the diameter of the normal adjacent arterial segment. Then the patients were classified according to the presence of CE, level of RDW, and other clinical and demographic characteristics. The RDW >14.8% was considered as elevated level. All groups were compared by chi-square and Pearson correlation analysis and Mann-Whitney U test according to the presence and distribution of CE. Coronary ectasia was found in the 24 patients and 15 of the ectatic vessels were also infarct-related artery. Although patients with CE did not differ in terms of age, sex, presence of diabetes mellitus, hypertension, previously diagnosed coronary heart disease, and multivessel disease significantly, elevated level of RDW was more common in the patients with CE (P 1⁄4 .01; Table 1). However, isolated ectasia in the infarct-related artery was not correlated with elevated level of RDW (53.3% vs 44.4%; P 1⁄4 .67). Coronary ectasia usually progress on the basis of diffuse atherosclerosis, chronic inflammatory process, and increased oxidative stress. Correlation between elevated level of RDW such mentioned clinical process were also shown with previous studies. Presence of CE may reflect the further exaggeration of the inflammatory response in the AMI, which could explain the correlation between elevated level of RDW and the CE, even adjustment for the AMI. In conclusion, elevated RDW level may also reflect CE in the patients with AMI. There was no significant correlation between elevated RDW level and isolated CE in the infarctrelated artery.

Novel CT-based imaging markers for high-risk coronary plaques

A large proportion of patients with suspected coronary artery disease who are referred for coronary computed tomography angiography (CTA) have coronary atherosclerotic lesions that do not cause significant anatomical luminal obstruction.1,2 These non-obstructive coronary artery lesions provide incremental prognostic information over the presence of obstructive lesions and clinical variables.1–5 However, the management of such lesions remains inadequately defined and there is a need for markers that could identify atherosclerotic plaques associated with high risk of events. Coronary plaques that are vulnerable to rupture and subsequent vessel thrombosis have been termed as thin cap fibroatheroma (TCFA) and show morphological features similar to disrupted plaques.6 Based on autopsy studies, they have large plaque volume associated with positive remodelling of the vessel and large necrotic core that are covered by a thin fibrous cap. …

113 Blood thrombogenicity is inversely related to coronary lesion severity in patients with non ST-elevation acute coronary syndrome and type 2 diabetes mellitus

In patients with type 2 diabetes mellitus (T2DM), non-ST elevation–acute coronary syndrome (NSTE-ACS) occurs frequently secondary to non-obstructive coronary lesions than those without T2DM. Pathophysiological events leading to acute myocardial...

Cardiac denervation procedure to treat refractory angina in a patient with Churg-Strauss syndrome and non-obstructive coronary lesions

Cardiac involvement in Churg-Strauss syndrome is common and represents the main cause of mortality. We report the case of a patient with Churg-Strauss vasculitis, mitral regurgitation with left ventricular dysfunction, paroxysmal atrial fibrillation and refractory angina with non-significant coronary lesions. Cardiac denervation was proposed as an associated procedure to treat angina. The total removal of peri-adventitial and adventitial tissue around the superior vena cava, ascending aorta and main pulmonary trunk was performed. After 3 months of follow-up, the patient was angina-free and could resume his normal lifestyle.

MUTYH Associated Polyposis Coli: One Common and One Rare Mutation

A 52-year-old Caucasian male with no significant medical history presented at our Department of Gastroenterology several years ago with vague complaints of abdominal distension, fecal urgency, and occasional hematochezia. There was no abdominal pain or weight loss. Familial history was unremarkable. Digital rectal examination revealed tumor at the tip of the finger, confirmed by rectoscopy as a fragile, non-obstructive lesion surrounded by multiple small polyps. A colonoscopy was performed which showed approximately 100 small sessile or pedunculated polyps throughout the large bowel. At 9 cm from the anal margin a concentric polypoid mass was identified, showing central ulceration. Pathological examination confirmed the presence of an invasive adenocarcinoma with strong CEA immunoreactivity. Biopsies of other polyps disclosed tubulovillous adenomata. Endoscopic ultrasound examination suggested penetration of the cancerous growth into the muscular layer. No metastatic disease was identified by CT examination of the abdomen. Final staging of the rectal tumor was T3N0M0. Considering the numerous polyps visualized by endoscopy, a tentative diagnosis of familial adenomatous polyposis (FAP) was made. In this case, total colectomy is the only curative treatment. Neo-adjuvant chemoradiation therapy was initiated (5-fluorouracil and Mitomycin) to downstage the lesion. Re-evaluation showed a considerable regression of the main rectal lesion, as well as the multiple colonic polyps. A total colectomy was performed with ileo-anal anastomosis and J-pouch construction. The patient is currently in regular follow-up and has no symptoms or signs of recurrent disease. Familial adenomatous polyposis is caused by mutations in the APC gene (adenomatous polyposis coli) located on chromosome 5. To our surprise, we could not identify the most common APC mutations in our patient. Considering the autosomal dominant inheritance of FAP, colonoscopy was also performed in the patient’s three children and found to be negative. In the meantime, his sister was also diagnosed in another hospital with rectal carcinoma and multiple colonic polyps. She was also treated by total colectomy. Taking into account the more recent scientific evidence, a new DNA analysis was performed in our patient. This showed two mutations of the MUTYH gene (Y165C and P391L). In contrast to FAP, MAP (MUTYH associated polyposis) is inherited in an autosomal recessive pattern, providing a solid explanation for the pedigree of our case.

The maximum necrotic core area is most often located proximally to the site of most severe narrowing: a virtual histology intravascular ultrasound study

Previous angiographic studies have shown that almost two-thirds of vulnerable plaques are located in non-obstructive lesions. Possibly, the maximum necrotic core (Max NC) area is not always identical to the site of most severe stenosis. Therefore, the purpose of this study was to evaluate the potential difference in location between the maximum necrotic core area and the site of most severe narrowing as assessed by virtual histology intravascular ultrasound (VH IVUS). Overall, 77 patients (139 vessels) underwent VH IVUS. The Max NC site was defined as the cross section with the largest necrotic core area per vessel. The site of most severe narrowing was defined as the minimum lumen area (MLA). Per vessel, the distance from both the Max NC site and MLA site to the origo of the coronary artery was evaluated. In addition, the presence of a virtual histology-thin cap fibroatheroma (VH-TCFA) was assessed. The mean difference (mm) between the MLA site and Max NC site was 10.8 ± 20.6 mm (p < 0.001). Interestingly, the Max NC site was located at the MLA site in seven vessels (5%) and proximally to the MLA site in 92 vessels (66%). Importantly, a higher percentage of VH-TCFA was demonstrated at the Max NC site as compared to the MLA site (24 vs. 9%, p < 0.001). In conclusion, the present findings demonstrate that the Max NC area is rarely at the site of most severe narrowing. Most often, the Max NC area is located proximal to the site of most severe narrowing.

Abstract 9917: The Site of Greatest Vulnerability is Most Often Located Proximally to the Site of Most Severe Narrowing: A Virtual Histology Intravascular Ultrasound Study

Introduction: Previous angiographic studies have shown that almost two-thirds of vulnerable plaques are located in non-obstructive lesions. However, the spatial relationship between the location of most severe narrowing and vulnerable rupture sites has not been fully elucidated. Probably, the site of greatest vulnerability is not always identical to the site of most severe stenosis. Therefore, the aim of the present study was to assess the spatial relationship between the location of the site of greatest vulnerability and the location of most severe narrowing with VH IVUS. Methods: Overall, 77 patients (139 vessels) underwent VH IVUS. The site of greatest vulnerability was defined as the cross-section with the largest necrotic core area per vessel, the maximum necrotic core (Max NC) site. The site of most severe narrowing was defined as the minimum lumen area (MLA). Per vessel the distance from both the Max NC site and MLA site to the origo of the coronary artery was evaluated. In addition, the presence of a thin cap fibroatheroma (TCFA) was assessed. Results: The mean difference (mm) between the MLA site and Max NC site was 10.8±20.6mm (P&lt;0.001). Interestingly, the Max NC site was located at the MLA site in 7 vessels (5%) and proximally to the MLA site in 92 vessels (66%). Besides, a higher % of TCFA was demonstrated at the Max NC site as compared to the MLA site (24% versus 9%, P&lt;0.001). Conclusion: The present findings demonstrate that the site of greatest vulnerability is rarely at the site of most severe narrowing. Most often, the site of greatest vulnerability is located proximally to the site of most severe narrowing. Furthermore a higher percentage of TCFA (plaque phenotype with high-risk of rupture) was demonstrated at the site of greatest vulnerability. Figure 1 Difference in distance (mm) and distribution between Max NC site and MLA site. In the majority of vessels the site of Max NC is located proximal to site of MLA.

Non-obstructive coronary artery disease upon multi-detector computed tomography in patients presenting with acute chest pain-Results of an intermediate term follow-up

Multi-detector computed tomography (MDCT) has emerged as an efficient tool for detection of obstructive coronary artery disease (CAD) and assessment of patients with acute chest pain. MDCT may detect premature, non-obstructive atherosclerotic lesions which otherwise would have not been detected upon functional cardiac imaging tests. Currently, there is scarce data regarding the clinical significance of these lesions. The purpose of this study was to prospectively analyse the intermediate term outcome of patients admitted to chest pain unit (CPU) with findings of non-obstructive CAD upon MDCT. Method and results The study comprised 444 patients admitted to the CPU at Sheba Medical Center and underwent evaluation by MDCT for complaints of acute chest pain. Studies were classified as: normal; non-obstructive CAD (defined as any narrowing <50% diameter stenosis); obstructive CAD (narrowing of ≥ 50% diameter stenosis); or non-diagnostic. Patients were followed up for a minimum of 1 year and outcomes were compared between the non-obstructive (n = 115) and the normal (n = 266) MDCT groups in regard to MACE [coronary revascularization, acute coronary syndrome (ACS), and death]. Comparing the groups, those with non-obstructive CAD were older, more likely to be males, and dyslipidaemic. During an intermediate term follow-up (2.5 ± 0.4 years) MACE was equally low between the two groups (1% for both groups; P = 0.9). Among patients evaluated by MDCT for acute chest pain, during an intermediate term follow-up, those with non-obstructive CAD had a benign clinical outcome compared with those with normal coronary arteries.

Coronary CT Angiography in Takayasu Arteritis

The aim of this study was to use coronary computed tomographic (CT) angiography to characterize coronary artery involvement in patients with known Takayasu arteritis who present with anginal chest pain or shortness of breath. Takayasu arteritis is a primary vasculitis of the large vessels, which mainly affects the aorta and its branches but can also involve the coronary arteries. Coronary CT angiography allows visualization of the coronary vessels and can be used to detect both stenotic and nonstenotic coronary artery lesions. Eighteen consecutive patients with Takayasu arteritis and angina (typical or atypical) and/or dyspnea underwent contrast-enhanced 64-slice coronary CT angiography. The arterial injury was classified according to the Numano classification. Three patients had prior known coronary artery disease. Coronary arteries were evaluated concerning the presence of obstructive and nonobstructive lesions, and differences between the clinical presentations of patients with and without coronary artery involvement on CT angiography were analyzed. Coronary artery involvement was found in 8 patients (44.4%), 3 of them with clinical activity. A total of 19 coronary lesions were present (13 in ostial locations, 5 in proximal coronary artery segments, and 1 in a mid segment). Eight lesions exceeded 50% diameter reduction (2 in ostial locations and 6 in proximal coronary artery segments). Median disease duration was significantly different between patients with coronary artery involvement (176 months; range 13 to 282 months) compared with those without (21 months; range 1 to 142 months) (p = 0.013). Coronary CT angiography allows the assessment of coronary artery involvement in patients with Takayasu arteritis. These data confirm prior observations that most coronary lesions are in ostial or proximal coronary artery locations. Disease duration in patients with coronary artery involvement is longer than in patients without.

Prognostic Implications of Nonobstructive Coronary Plaques in Patients With Non–ST-Segment Elevation Myocardial Infarction: A Multidetector Computed Tomography Study

We sought to determine whether the amount of noncalcified plaque (NCP) in nonobstructive coronary lesions as detected by multidetector computed tomography (MDCT) was a predictor of future coronary events. Patients presenting with non–ST-segment elevation myocardial infarction (NSTEMI) frequently have multiple coronary plaques, which may be detected with MDCT. We included 312 consecutive patients presenting with NSTEMI, who underwent 64-slice MDCT coronary angiography and coronary artery calcium scoring before invasive coronary angiography. All patients were treated according to current guidelines based on an invasive treatment approach. Quantitative measurements of plaque composition and volume were performed by MDCT in all nonobstructive coronary lesions. The endpoint was cardiac death, acute coronary syndrome, or symptom-driven revascularization. After a median follow-up of 16 months, 23 patients had suffered a cardiac event. Age, male sex, and diabetes mellitus were all associated with an increasing amount of NCP. In a multivariate regression analysis for events, the total amount of NCP in nonobstructive lesions was independently associated with an increased hazard ratio (1.18/100-mm3 plaque volume increase, p = 0.01). Contrary to this, neither Agatston score nor the amount of calcium in nonobstructive lesions was associated with an increased risk. Multidetector computed tomography plaque imaging identified patients at increased risk of recurrent coronary events after NSTEMI by measuring the total amount of NCP in nonobstructive lesions. The amount of calcified plaque was not associated with an increased risk.

Prognostic performance of low-dose coronary CT angiography with prospective ECG triggering

ObjectiveTo assess the prognostic value of low-dose 64-slice coronary CT angiography (CCTA) using prospective ECG triggering in a patient population with known or suspected coronary artery disease (CAD).DesignLongitudinal follow-up study.SettingTertiary...

Comparison of carotid and cerebrovascular disease between diabetic and non-diabetic patients using dual-source CT

To clarify the differences of the carotid and cerebrovascular disease between patients with and without type 2 diabetes using dual-source CT angiography. Dual-source CT angiography of the carotid and cerebrovascular arteries was performed in 79 type 2 diabetic patients and 207 non-diabetic patients. The type, extent and distribution of plaques, and luminal stenosis were compared. Compared with non-diabetic patients, diabetic patients had a higher overall incidence of plaque (p<0.05) and cerebral infarction (p<0.05). Among these plaques, no differences were observed in the subtype of plaques between these two cohorts (all p>0.05), as well as for the number of diseased segments and the distribution of plaques; both mainly involved the bilateral cavernous segment of the internal carotid artery. As for the stenosis, non-obstructive lesions were more common in diabetic patients (p<0.05). There was no difference in the segment number of stenosis (≥30% and ≥70%) between these two groups (all p>0.05). Diabetes is associated with a higher incidence of plaque and non-obstructive stenosis. However, no significant differences were observed in the type, extent and distribution of involved plaques between diabetic and non-diabetic patients.

Sex Differences in Mortality Associated With Computed Tomographic Angiographic Measurements of Obstructive and Nonobstructive Coronary Artery Disease

Background— Sex differences exist in the prevalence and severity of obstructive coronary artery disease (CAD). Limited data are available to explore sex differences in prognosis with coronary computed tomographic angiographic (CCTA) measurements of CAD including novel nonobstructive plaque extent. Methods and Results— A total of 1127 consecutive patients were clinically referred to 16-slice CCTA and followed for the occurrence of all-cause death. Time to death was calculated by univariable and multivariable Cox proportional hazard models. Four-year survival (92.1%) was similar by sex ( P =0.52). Women more often had no coronary stenosis (54%) as compared with men (28%) ( P &lt;0.0001). Mortality worsened for both women ( P &lt;0.0001) and men ( P =0.002) by the number of vessels with ≥50% stenosis. For women, overall mortality ranged from 3.5% for no CAD to 25.0% for women with 3-vessel plus left main obstructive CAD ( P &lt;0.0001). For men, overall mortality ranged from 2.7% for no CAD to 17.4% for males with 3-vessel plus left main obstructive CAD ( P =0.002). Nonobstructive disease was prevalent in women (range, 24% to 66%) and men (range, 45% to 74%) ages 45 to ≥80 years. Nonobstructive CAD extent was a significant estimator of all-cause mortality when added to a model containing pretest CAD likelihood and obstructive CAD extent ( P =0.039). For men, in a risk-adjusted model including pretest CAD likelihood and obstructive CAD, the number of nonobstructive lesions was not a significant estimator of mortality ( P =0.9). For women, the relative hazard for mortality, in a multivariable model, was 1.3 per nonobstructive lesion ( P =0.003), including pretest CAD likelihood and obstructive CAD as covariates. For women, risk-adjusted median mortality ranged from 2.9% to 10.9% for none to ≥4 nonobstructive lesions ( P &lt;0.0001). Conclusions— Based on our preliminary analyses, CCTA obstructive and nonobstructive CAD adds incremental value to clinical assessment for risk stratification. Moreover, the extent of nonobstructive CAD by CCTA predicts mortality in women but not in men and may be helpful to optimize therapeutic strategies for women.

Vascular endothelial function and carotid intima-media thickness in patients with isolated coronary artery ectasia and exercise-induced angina pectoris

Coronary artery ectasia (CAE) has been defined as localized or diffuse nonobstructive lesions of the epicardial coronary arteries with a luminal dilatation≥1.5 times of the adjacent normal segments [1]. And, isolated CAE was defined as CAE without significant stenosis or occlusion of the coronary artery [2]. The etiology of CAE is obscure and usually considered a variant of coronary atherosclerosis [1,3,4]. However, the atherosclerotic process is not mandatory for ectatic transformation [5,6]. Recent evidence suggest that the mechanism underlying the development of CAE is a diffuse vascular pathology of the medial layer rather than a localized coronary atherosclerosis [7–9].