Obstructive Stenosis Research Articles

Comparison between coronary calcium score and segment involvement score when used in clinical routine

Abstract Data from a nationwide registry on coronary computer tomography angiography. Background The Coronary Artery Calcium Score (CACS) and segment involvement score (SIS) are crucial factors in assessing the severity of coronary artery disease (CAD) and determining the likelihood of future cardiovascular events. However, there are few large multicenter studies comparing the predictive value of CACS and SIS when used in the clinical routine. Objectives To compare CACS and SIS ability to predict cardiovascular outcomes when used in the clinical routine. Methods This retrospective cohort study included patients who underwent Coronary Computed Tomography Angiography (CCTA) for CAD evaluation between 2006-2022 in 29 different centers in Sweden. CACS was calculated using the Agatston method, and SIS was determined based on the number of coronary segments exhibiting plaque. For SIS, patients were categorized into SIS=0, SIS=1, SIS=2, SIS=3, SIS³4, for CACS patients were categorized into CACS=0, CACS=1-9, CACS=10-99, CACS=100-299, CACS³300. Patients were followed regarding the primary outcome of death or myocardial infarction. Multivariable Cox proportional hazards models were used for adjusting for potential confounders. Results A total of 23034 patients underwent CCTA and were followed for up to ten years. Median age (IQR) was 58 (49–67) years, 50% were women, 9% had diabetes mellitus, 42% had hypertension, 25% had hyperlipidemia, 5% had previously known CAD. There were 955 patients (4.1%) with myocardial infarction (MI) and 409 patients (2.2%) died during follow up. There was an increase in cardiovascular events with increasing SIS. When comparing SIS and presence of obstructive stenosis, SIS was a better predictor of outcome (Figure 1). There was also an increase cardiovascular events with increasing CACS (Figure 2). When adjusted for age, sex, risk factors, previous cardiovascular disease and intervention, both SIS and CACS were independently associated with outcome. When SIS and CACS were compared in a receiver operating characteristic curve, CACS had significantly larger AUC than SIS, (0.70[0.67-0.73] vs 0.62[0.60-0.63]). Conclusion Our findings show that both CACS and SIS are important and independent predictors of cardiovascular outcomes thereby offering a valuable tool for personalized risk stratification and management in clinical settings. When used in the clinical routine, CACS appears to be more strongly associated with outcome than SIS.Figure1 Survival SISFigure 2 Survival CACS

Prognostic value of quantitative anatomical and functional measures of coronary artery disease in diabetic and non-diabetic patients

Abstract Background Diabetes is associated with increased risk of coronary artery disease (CAD). However, the relative prognostic importance of anatomical and functional findings of CAD in the presence vs. absence of diabetes is incompletely understood. Technological advances have made quantitative analysis of coronary artery plaques and stenosis feasible by coronary computed tomography angiography (CTA). In turn, positron emission tomography (PET) enables absolute quantification of myocardial blood flow (MBF). Purpose To study long-term prognostic value of quantified severity of coronary atherosclerosis and myocardial perfusion in non-diabetic vs. diabetic patients with suspected CAD. Methods From two academic medical centres, we identified symptomatic patients with suspected CAD who had undergone coronary CTA and [15O]H2O PET myocardial perfusion imaging during adenosine stress. Based on artificial intelligence -guided quantitative analysis of coronary CTA scans, the anatomical severity of CAD was measured as the presence of obstructive CAD (≥50% diameter stenosis) and percent atheroma volume (PAV; higher vs. lower than median). The functional severity of CAD was measured as the presence of regional myocardial ischemia (≥2 adjacent segments with stress MBF <2.3 ml/g/min) and global stress MBF (<2.2 ml/g/min vs. ≥ 2.2 ml/g/min) by PET. Annual rates of adverse events (AER) including all-cause mortality, myocardial infarction (MI), and unstable angina pectoris (UAP) were evaluated. Results Among 1311 patients, 251 (19%) had diabetes. Patients with diabetes had more frequently obstructive CAD (55% vs. 43%, p<0.001) and regional myocardial ischemia (51% vs. 43%, p=0.015), higher plaque burden by PAV (12% vs. 7%, p<0.001), and lower global stress MBF (2.78 ml/g/min vs. 3.05 ml/g/min, p<0.001). During median follow-up of 7.1 years, 171 (13.0%) patients experienced AE (85 deaths, 56 MIs, and 30 UAPs). Patients with diabetes had higher AER than non-diabetic patients (3.1% vs. 1.6%, p<0.001). The presence of obstructive stenosis was associated with increased AER in non-diabetic (2.6% vs. 1.0%, p<0.001) and diabetic patients (4.2% vs. 1.9%, p<0.001). High plaque burden by PAV was associated with increased AER in non-diabetic (2.8% vs. 0.7%, p<0.001) and diabetic patients (3.9% vs. 1.7%, p<0.001). The presence of regional myocardial ischemia was associated with increased AER in non-diabetic (2.5% vs. 1.1%, p<0.001), but not in diabetic patients (3.4% vs. 2.7%, p=0.238). Low global stress MBF was associated with increased AER in non-diabetic (2.9% vs. 1.3%, p<0.001), but not among diabetic patients (3.2% vs. 3.0%, p=0.286). Conclusions Diabetes was associated with more advanced CAD. Quantified severity of anatomical findings predicted long-term adverse outcome in non-diabetic and diabetic patients. In contrast, functional imaging risk stratified non-diabetic patients, whereas diabetic patients had impaired long-term outcome irrespective of perfusion findings.

CT-FFR by expanding coronary tree with Newton-Krylov-Schwarz method to solve the governing equations of CFD.

A new model of computational fluid dynamics (CFD)-based algorithm for coronary CT angiography (CCTA)-derived fractional flow reserve (FFR) (CT-FFR) analysis by expanding the coronary tree to smaller-diameter lumen (0.8 mm) using Newton-Krylov-Schwarz (NKS) method to solve the three-dimensional time-dependent incompressible Navier-Stokes equations has been developed; however, the diagnostic performance of this new method has not been sufficiently investigated. The aim of this study was to determine the diagnostic performance of a novel CT-FFR technique by expanding the coronary tree in the CFD domain. Six centres enrolled 338 symptomatic patients with suspected or known coronary artery disease (CAD) who prospectively underwent CCTA and FFR. Stenosis assessment in CCTA and CT-FFR analysis were performed in independent core laboratories. Haemodynamically significant stenosis was defined by a CT-FFR and FFR ≤ 0.80, and anatomically obstructive CAD was defined as a CCTA with stenosis ≥ 50%. Diagnostic performance of CT-FFR was evaluated against invasive FFR using receiver operating characteristic (ROC) curve analysis. The correlation between CT-FFR and invasive FFR was analysed using the Spearman correlation coefficient and Bland-Altman analysis. Intra-observer and inter-observer agreements were evaluated utilizing the intraclass correlation coefficient (ICC). In this study, 338 patients with 422 targeted vessels were investigated, revealing haemodynamically significant stenosis in 31.1% (105/338) of patients and anatomically obstructive stenosis in 54.1% of patients. On a per-vessel basis, the area under the ROC curve for CT-FFR was 0.94 vs. 0.76 for CCTA (P < 0.001). Per-vessel accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 89.8%, 89.3%, 90.0%, 79.0%, and 99.2%, respectively, for CT-FFR and were 68.4%, 82.8%, 62.3%, 48.1%, and 89.6%, respectively, for CCTA stenosis. CT-FFR and FFR were well correlated (r = 0.775, P < 0.001) with a Bland-Altman bias of 0.0011, and limits of agreement from -0.1509 to 0.1531 (P = 0.770). The ICCs with CT-FFR for intro- and inter-observer agreements were 0.919 (95% CI: 0.866-0.952) and 0.909 (95% CI: 0.851-0.945), respectively. The average computation time for CT-FFR analysis was maintained at 11.7 min. This novel CT-FFR model with the inclusion of smaller lumen provides high diagnostic accuracy in detecting haemodynamically significant CAD. Furthermore, the integration of the NKS method ensures that the computation time remains within an acceptable range for potential clinical applications in the future.

Prosthetic valve dysfunction in patients with mechanical heart valves: Results from the Emergency Salam Centre cohort

IntroductionMechanical heart valve (MHV) replacement requires long-life anticoagulation due to the risk of Prosthetic Valve Dysfunction (PVD) and cardioembolism. MethodsWe report data from a prospective observational study conducted on MHV patients in the Khartoum Salam Centre for Cardiac Surgery built by ‘Emergency,’ an Italian Non-Governmental Organization, to evaluate the occurrence of PVD and associated risk factors. ResultsWe prospectively followed 3647 patients, and 38 patients (rate 1.04 × 100 pt-years) had PVD during follow-up. The time in therapeutic range (TTR) among patients without PVD was 53 % (IQR 37–67), and it was 43 % (IQR 19–58) among patients with PVD (p = 0.04). Twenty-three over 38 patients (60.5 %) were symptomatic, 18 (47.4 %) had obstructive valvular stenosis, 24 patients (63.2 %) had INR <2.0 at diagnosis, and 21 patients (55.3 %) had been off warfarin for a long time: 3 patients for 1 week, 1 patient for 2 weeks, and 17 patients for >4 weeks (6 patients were off warfarin from 3 to 12 months). Ten were uncompliant to treatment, and 8 were pregnant women. Ten patients (26.3 %) with PVD had had a previous episode of PVD, and 14 patients (36.8 %) had 2 or more associated risk factors. Only in 6 cases were no associate risk factors found. ConclusionsAmong MHV patients on warfarin treatment with a sub-optimal quality of anticoagulation, the rate of PVD is 1.04 % pt-years, and the most frequent associated risk factor for PVD occurrence is warfarin withdrawal lasting more than one week.

Transient ischemic mitral regurgitation caused by non obstructive coronary lesion

Cases of transient ischemic mitral regurgitation caused by obstructive coronary artery stenosis have been reported in literature. But it can also be caused by non-obstructive coronary lesions. Diagnosis requires high suspicion and clinical acumen backed by a complete cardiac work-up that correlates with the timing of the coronary vasospasm.

Uric acid to albumin ratio as a novel predictor for coronary slow flow phenomenon in patients with chronic coronary syndrome and non-obstructive coronary arteries

BackgroundThe plasma uric acid to albumin ratio (UAR) is considered as a novel indicator for Inflammation. However, the association between UAR and coronary slow flow phenomenon (CSFP) remains unclear.MethodsA total of 1328 individuals with chronic coronary syndrome (CCS) receiving coronary angiography (CAG) and found no obvious obstructive stenosis (< 40%) were included in this study. 79 individuals developed CSFP and were divided into CSFP group. The 1:2 age-matched patients with normal coronary blood flow were allocated to the control group (n = 158). The clinical characteristics, laboratory parameters including uric acid, albumin ratio, UAR and the angiographic characteristics were compared between the two groups.ResultsPatients with CSFP had a higher level of uric acid (392.3 ± 85.3 vs. 273.8 ± 71.5, P < 0.001), UAR (10.7 ± 2.2 vs. 7.2 ± 1.9, P < 0.001), but a lower level of plasma albumin (36.9 ± 4.2 vs. 38.5 ± 3.6, P = 0.003). Moreover, UAR increased as the numbers of vessels involved in CSFP increased. The logistic regression analysis demonstrated that UAR was independent predictors for CSFP. The Receiver operating characteristic (ROC) curve analysis showed that when UAR was more than 7.9, the AUC was 0.883 (95% CI: 0.840–0.927, p < 0.001), with the sensitivity and specificity were 78.2% and 88.2% respectively.ConclusionCombined uric acid with plasma albumin, UAR could serve as an independent predictor for CSFP.

Aggravating effect of abnormal low-density protein cholesterol level on coronary atherosclerotic plaque in type 2 diabetes mellitus patients assessed by coronary computed tomography angiography

BackgroundThe abnormal low-density protein cholesterol (LDL-C) level in the development of atherosclerosis is often comorbid in individuals with type 2 diabetes mellitus(T2DM). This study aimed to investigate the aggravating effect of abnormal LDL-C levels on coronary artery plaques assessed by coronary computed tomography angiography (CCTA) in T2DM.Materials and methodsThis study collected 3439 T2DM patients from September 2011 to February 2022. Comparative analysis of differences in coronary plaque characteristics was performed for the patients between the normal LDL-C level group and the abnormal LDL-C level group. Factors with P < 0.1 in the univariable linear regression analyses were included in the multivariable linear stepwise regression.ResultsA total of 2820 eligible T2DM patients were included and identified as the normal LDL-C level group (n = 973) and the abnormal LDL-C level group (n = 1847). Compared with the normal LDL-C level group, both on a per-patient basis and per-segment basis, patients with abnormal LDL-C level showed more calcified plaques, partially calcified plaques, low attenuation plaques, positive remodellings, and spotty calcifications. Multivessel obstructive disease (MVD), nonobstructive stenosis (NOS), obstructive stenosis (OS), plaque involvement degree (PID), segment stenosis score (SSS), and segment involvement scores (SIS) were likely higher in the abnormal LDL-C level group than that in the normal LDL-C level group (P < 0.001). In multivariable linear stepwise regression, the abnormal LDL-C level was validated as an independent positive correlation with high-risk coronary plaques and the degree and extent of stenosis caused by plaques (low attenuation plaque: β = 0.116; positive remodelling: β = 0.138; spotty calcification: β = 0.091; NOS: β = 0.427; OS: β = 0.659: SIS: β = 1.114; SSS: β = 2.987; PID: β = 2.716, all P value < 0.001).ConclusionsAbnormal LDL-C levels aggravate atherosclerotic cardiovascular disease (ASCVD) in patients with T2DM. Clinical attention deserves to be caught by the tailored identification of cardiovascular risk categories in T2DM individuals and the achievement of the corresponding LDL-C treatment goal.

Importance of provoked spasms at the sites of nonobstructive stenosis as well as at the sites of obstructive stenosis in patients with obstructive coronary arteries and coronary spasm.

There are few reports regarding the prognosis in patients with obstructive coronary artery disease (OCAD) and vasospastic angina (VSA). This study investigated the clinical characteristics and clinical outcomes in patients with VSA and OCAD, especially regarding provoked spasm phenotypes and sites. This was a retrospective, observational, single-center study of 403 patients with typical or atypical angina-like chest pain undergoing acetylcholine (ACH) spasm provocation testing and OCAD. An obstructed coronary artery was defined as ≥50% luminal narrowing. We defined positive epicardial spasm as ≥90% transient stenosis and usual chest symptoms or ischemic ECG changes. Among these 403 patients with OCAD, positive spasm by intracoronary ACH testing was observed in 196 patients (49%), whereas negative spasm was found in the remaining 207 patients (51%). The clinical outcomes in the patients with OCAD and provoked spasm were not different according to the provoked-spasm phenotypes. Furthermore, the clinical outcomes were unsatisfactory in the patients with spasm at the site of nonobstructive lesion alone compared with those with spasm at the site of obstructive and nonobstructive lesions. We should precisely diagnose patients with OCAD who have provoked spasm by using intracoronary ACH testing and medicate the nonobstructive vessels in patients with OCAD and VSA under optimal coronary vasodilators.

Novel motion correction algorithm improves diagnostic performance of CT fractional flow reserve

ObjectivesThis study aimed to investigate the diagnostic performance of computed tomography (CT) fractional flow reserve (CT-FFR) derived from standard images (STD) and images processed via first-generation (SnapShot Freeze, SSF1) and second-generation (SnapShot Freeze 2, SSF2) motion correction algorithms. Methods151 patients who underwent coronary CT angiography (CCTA) and invasive coronary angiography (ICA)/FFR within 3 months were retrospectively included. CCTA images were reconstructed using an iterative reconstruction technique and then further processed through SSF1 and SSF2 algorithms. All images were divided into three groups: STD, SSF1, and SSF2. Obstructive stenosis was defined as a diameter stenosis of ≥ 50 % in the left main artery or ≥ 70 % in other epicardial vessels. Stenosis with an FFR of ≤ 0.8 or a diameter stenosis of ≥ 90 % (as revealed via ICA) was considered ischemic. In patients with multiple lesions, the lesion with lowest CT-FFR was used for patient-level analysis. ResultsThe overall quality score in SSF2 group (median = 3.67) was markedly higher than that in STD (median = 3) and SSF1 (median = 3) groups (P < 0.001). The best correlation (r = 0.652, P < 0.001) and consistency (mean difference = 0.04) between the CT-FFR and FFR values were observed in the SSF2 group. At the per-lesion level, CT-FFRSSF2 outperformed CT-FFRSSF1 in diagnosing ischemic lesions (area under the curve = 0.887 vs. 0.795, P < 0.001). At the per-patient level, the SSF2 group also demonstrated the highest diagnostic performance. ConclusionThe SSF2 algorithm significantly improved CCTA image quality and enhanced its diagnostic performance for evaluating stenosis severity and CT-FFR calculations.

Comparison of risk profiles of participants in the Women's IschemiA TRial to Reduce events In non-ObstRuctive CAD (WARRIOR) trial, using Coronary Computed Tomography Angiography vs Invasive Coronary Angiography

ObjectiveTo compare baseline characteristics of participants in the Women's IschemiA TRial to Reduce Events In Non-ObstRuctive CAD (WARRIOR) trial by qualification by Coronary Computed Tomography Angiography (CCTA) or Invasive Coronary Angiography (ICA). MethodsThe WARRIOR trial (NCT03417388) is an ongoing multicenter, prospective, randomized, blinded outcome evaluation of intensive medical therapy vs. usual care in women with suspected Ischemia and No Obstructive Coronary Artery Disease (INOCA) identified by either CCTA or ICA on the outcome of major adverse cardiovascular events (MACE). No obstructive coronary artery disease is defined as <50% luminal stenosis and normal coronary arteries is defined as no evidence of atherosclerosis including calcified and non-calcified plaque. Data presented was extracted on May 27, 2020. No clinical outcomes were assessed. ResultsAn initial sample cohort of 797 women was included. The majority were younger than 65 years, White participants (73.3%), 159 had diabetes (19.9%), and 676 had angina (84.8%) with the remainder having symptoms of suspected ischemic heart disease. Over 50% of randomized participants had normal coronaries without luminal irregularities by ICA or CCTA. Participants randomized to ICA were more likely to have worse baseline clinical risk profiles with older age, higher burden of cardiac risk factors and poor quality of life with disabling angina. ConclusionsAmong this initial sample of women with suspected INOCA randomized in the WARRIOR trial, there is a differential baseline cardiac risk of participants enrolled after CCTA or ICA. However, the majority had no evidence of atherosclerotic plaque or obstructive stenosis, after evaluation by ICA or CCTA. These results suggest that non-invasive evaluation with CCTA is likely to be associated with lower risk of MACE.

Screening, risk stratification and CT imaging for assessment of coronary artery disease

Early treatment of cardiovascular risk factors and characterization of coronary plaques is essential to collect prognostic information about coronary artery disease (CAD) and prevent cardiovascular events. Discussion of the most important risk factors of CAD, basic diagnostic of CAD, prevention, and prognostic factors of CAD with focus on cardiac computed tomography (CT). Prevalence and prognostic impact of CAD risk factors; description of specific assessment of risk profiles; estimation of pretest probability; conventional prevention of CAD; prognostic assessment of CAD using the Calcium Scoring and coronary CT angiography. Assessment of risk profiles and estimation of pretest probability for obstructive coronary stenosis necessitates athorough evaluation of medical history and laboratory values. The composition and extent of calcified and noncalcified plaques in CT exams based on the criteria of the Coronary Artery Disease-Reporting and Data System give important prognostic information about the risk of cardiovascular events, which increases with high plaque burden and vice versa. Initial imaging with CT for evaluation of CAD leads to areduction of invasive coronary angiographies and catheter-associated complications. Besides early detection of cardiovascular risk factors, the additional assessment of plaque burden and significant stenosis in CT gives further prognostic information to facilitate effective therapies to prevent cardiovascular events and in the case of low plaque burden avoid invasive coronary angiography. However, systmatic screening using Calcium Scoring is not established yet due to insufficient data, although it could potentially be used for an early risk stratification in patients with multiple risk factors.

Development and Validation of a Quantitative Coronary CT Angiography Model for Diagnosis of Vessel-Specific Coronary Ischemia

BackgroundNoninvasive stress testing is commonly used for detection of coronary ischemia but possesses variable accuracy and may result in excessive health care costs. ObjectivesThis study aimed to derive and validate an artificial intelligence-guided quantitative coronary computed tomography angiography (AI-QCT) model for the diagnosis of coronary ischemia that integrates atherosclerosis and vascular morphology measures (AI-QCTISCHEMIA) and to evaluate its prognostic utility for major adverse cardiovascular events (MACE). MethodsA post hoc analysis of the CREDENCE (Computed Tomographic Evaluation of Atherosclerotic Determinants of Myocardial Ischemia) and PACIFIC-1 (Comparison of Coronary Computed Tomography Angiography, Single Photon Emission Computed Tomography [SPECT], Positron Emission Tomography [PET], and Hybrid Imaging for Diagnosis of Ischemic Heart Disease Determined by Fractional Flow Reserve) studies was performed. In both studies, symptomatic patients with suspected stable coronary artery disease had prospectively undergone coronary computed tomography angiography (CTA), myocardial perfusion imaging (MPI), SPECT, or PET, fractional flow reserve by CT (FFRCT), and invasive coronary angiography in conjunction with invasive FFR measurements. The AI-QCTISCHEMIA model was developed in the derivation cohort of the CREDENCE study, and its diagnostic performance for coronary ischemia (FFR ≤0.80) was evaluated in the CREDENCE validation cohort and PACIFIC-1. Its prognostic value was investigated in PACIFIC-1. ResultsIn CREDENCE validation (n = 305, age 64.4 ± 9.8 years, 210 [69%] male), the diagnostic performance by area under the receiver-operating characteristics curve (AUC) on per-patient level was 0.80 (95% CI: 0.75-0.85) for AI-QCTISCHEMIA, 0.69 (95% CI: 0.63-0.74; P < 0.001) for FFRCT, and 0.65 (95% CI: 0.59-0.71; P < 0.001) for MPI. In PACIFIC-1 (n = 208, age 58.1 ± 8.7 years, 132 [63%] male), the AUCs were 0.85 (95% CI: 0.79-0.91) for AI-QCTISCHEMIA, 0.78 (95% CI: 0.72-0.84; P = 0.037) for FFRCT, 0.89 (95% CI: 0.84-0.93; P = 0.262) for PET, and 0.72 (95% CI: 0.67-0.78; P < 0.001) for SPECT. Adjusted for clinical risk factors and coronary CTA-determined obstructive stenosis, a positive AI-QCTISCHEMIA test was associated with aHR: 7.6 (95% CI: 1.2-47.0; P = 0.030) for MACE. ConclusionsThis newly developed coronary CTA-based ischemia model using coronary atherosclerosis and vascular morphology characteristics accurately diagnoses coronary ischemia by invasive FFR and provides robust prognostic utility for MACE beyond presence of stenosis.

Updates on Prognostication of Takotsubo Cardiomyopathy: A Literature Review

Abstract Takotsubo cardiomyopathy (TTC), commonly known as “broken heart syndrome” or “stress cardiomyopathy,” is characterized by transient left ventricular (LV) systolic dysfunction, usually in the absence of significant obstructive coronary artery stenosis. The pathophysiology of TTC remains elusive; however, the three most common plausible mechanisms include catecholamine surge causing myocardial stunning, multivessel coronary spasm, and microvascular dysfunction. Although initially thought to be a benign, reversible, and transient disorder, newer research data demonstrate that TTC may sometimes have severe short-term complications and some long-term residual effects. Several risk factors have been associated with the outcomes of TTC. In this review, we aim to provide a comprehensive review of the prognostication of TTC in the context of different clinical variables presented in multiple research studies. Various clinical factors, including the types of TTC triggers, the patient’s sex, the presence of cardiogenic shock, atrial arrhythmias, LV tract obstruction, and the presence of certain other clinical comorbidities may significantly impact patient outcomes in TTC patients. A thorough understanding of these factors helps clinicians to better prognosticate the outcome of their patients. Furthermore, early institution of aggressive treatment interventions in the presence of these risk factors may improve the subsequent clinical course.

Diagnostic Performance of On-Site Automatic Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve.

Fractional flow reserve (FFR) is an invasive standard method to identify ischemia-causing coronary artery disease (CAD). With the advancement of technology, FFR can be noninvasively computed from coronary computed tomography angiography (CCTA). Recently, a novel simpler method has been developed to calculate on-site CCTA-derived FFR (CT-FFR) with a commercially available workstation. A total of 319 CAD patients who underwent CCTA, invasive coronary angiography, and FFR measurement were included. The primary outcome was the accuracy of CT-FFR for defining myocardial ischemia evaluated with an invasive FFR as a reference. The presence of ischemia was defined as FFR ≤0.80. Anatomical obstructive stenosis was defined as diameter stenosis on CCTA ≥50%, and the diagnostic performance of CT-FFR and CCTA stenosis for ischemia was compared. Among participants (mean age 64.7±9.4 years, male 77.7%), mean FFR was 0.82±0.10, and 126 (39.5%) patients had an invasive FFR value of ≤0.80. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CT-FFR were 80.6% (95% confidence interval [CI], 80.5-80.7%), 88.1% (95% CI, 82.4-93.7%), 75.6% (95% CI, 69.6-81.7%), 70.3% (95% CI, 63.1-77.4%), and 90.7% (95% CI, 86.2-95.2%), respectively. CT-FFR had higher diagnostic accuracy (80.6% vs. 59.1%, p<0.001) and discriminant ability (area under the curve from receiver operating characteristic curve 0.86 vs. 0.64, p<0.001), compared with anatomical obstructive stenosis on CCTA. This novel CT-FFR obtained from an on-site workstation demonstrated clinically acceptable diagnostic performance and provided better diagnostic accuracy and discriminant ability for identifying hemodynamically significant lesions than CCTA alone.

Dietary Composition, Angiographic Coronary Disease, and Cardiovascular Outcomes in the WISE Study (Women's Ischemia Syndrome Evaluation).

Studies relating diet to angiographic coronary artery disease (CAD) and subsequent major adverse cardiac events (MACE) in women are limited. Information on diet was collected in the Women's Ischemia Syndrome Evaluation (WISE), a prospective cohort study of symptomatic women referred for coronary angiography to evaluate suspected ischemic heart disease. A consecutive subgroup (n = 201 of 936) of enrolled women completed the modified Block food frequency questionnaire (FFQ). Data on outcomes were collected and adjudicated after 8-year follow-up. A set of logistic regression models were fitted for non-obstructive versus obstructive coronary stenosis (<50% versus ≥50%). Cox proportional hazard regression models were fitted for outcomes, with each dietary composition variable adjusted for the degree of coronary stenosis. At baseline, the subgroup cohort was 58 ± 12 years old with a body mass index (BMI) of 30 ± 7 kg/m2. An increased proportion of calories consumed from protein was associated with higher levels of baseline obstructive coronary stenosis. Those individuals who ate a higher amount of protein, carotene, and servings of vegetables and meat, however, were each associated with lower subsequent adverse outcomes, respectively. Among women undergoing coronary angiography for suspected CAD, a higher percentage of protein intake was associated with higher baseline stenosis severity; however, the amount of protein intake, vegetable, meat, and carotene intake, was conversely associated with subsequent lower adverse cardiovascular outcome risk.

Highly Inflamed Non-Calcified Coronary Plaques Sealed with Stents in Patients with Zero Calcium Score – a Case Series and Review of the Literature

Abstract The modern management of coronary artery disease (CAD) uses coronary computed tomography angiography (CCTA) to enhance plaque evaluation and cardiovascular risk assessment. CCTA identifies high-risk plaques, and the latest CT technologies based on calculation of fat attenuation index (FAI) allow assessment of inflammation at the level of the target coronary artery. We present a series of case studies with chest pain and positive CCTA, in whom a significant stenosis was detected in the left anterior descendent coronary artery, and the existence of high-risk, inflamed plaques was documented even in the context of a zero calcium score. A severe narrowing of the left anterior descending artery, exhibiting the pattern of high-risk anatomy, was associated with a very high inflammation depicted by FAI analysis in all three cases, an association that may be extremely dangerous. In this case series, CCTA examination led to immediate stenting of the obstructive stenosis, sealing the dangerous plaque.

An automated reduced order CT-FFR model for diagnosis of hemodynamically significant coronary artery disease- a prospective validation study

Abstract Background/Introduction CT derived fractional flow reserve (CT-FFR) is introduced in current guidelines as a gatekeeper for invasive coronary angiography (ICA) in symptomatic patients with intermediate stenoses on coronary CT angiography (CCTA). Traditionally, CT-FFR is validated with knowledge of the precise location of invasive FFR measurements to ensure a direct comparison. However, in a clinical setting, this information will not be available and may affect the diagnostic performance of CT-FFR. Purpose To validate the diagnostic performance of a novel physics augmented machine learning algorithm based on reduced order modelling for CT-FFR calculations, with an automated method for defining the site of CT-FFR evaluations. Methods In this prospective validation study, 108 consecutive patients with stable coronary artery disease (CAD) and at least one suspected obstructive stenosis of questionable hemodynamic significance on CCTA were included. All patients underwent a clinically indicated invasive coronary angiography. The diagnostic performance of the CT-FFR algorithm was assessed with invasive FFR at a threshold of ≤ 0,80 as reference standard. CT-FFR at the location of invasive FFR measurements (CT-FFRatloc) was compared with CCTA, CT-FFR at automatically selected locations (CT-FFRauto) and CT-FFR predictions at the distal end of the vessel (CT-FFRdistal). Results CT-FFRatloc showed good correlation with invasive FFR measurements (r=0,67) and demonstrated improved diagnostic performance compared to CCTA diameter stenosis ≥50%. alone both at lesion level (AUC= 0,85 vs 0,63, p&amp;lt;0,01) and at patient level (AUC=0,87 vs 0,74, p&amp;lt;0,01). Both specificity (84% vs 40%, p=0,01) and accuracy (81% vs 63%, p&amp;lt;0,01) of CT-FFRatloc was significantly increased compared to CCTA. CT-FFRauto performed equally well as CT-FFRatloc, both at lesion level (AUC= 0,82 vs AUC= 0,85, p=0,27) and patient level (AUC= 0,86 vs AUC= 0,87(p=0,67). When comparing CT-FFRdistal to CT-FFRatloc the overall diagnostic performance was poorer (AUC=0,79 vs 0,85, p&amp;lt;0,01). Conclusions Compared to CCTA, CT-FFRatloc showed improved diagnostic performance, including accuracy and specificity for the detection of hemodynamically significant coronary artery disease in a symptomatic population. Predictions using an automated location algorithm, CT-FFRauto, was comparable to evaluations at the location of invasive FFR measurements, CT-FFRatloc.Figure 1Figure 2

Abstract 16989: Clonal Hematopoiesis of Indeterminate Potential Status is Associated With Left Main Artery Stenosis

Introduction: Clonal hematopoiesis of indeterminate potential (CHIP) occurs secondary to acquired mutations in bone marrow progenitor cells. CHIP confers a twofold risk of atherosclerotic cardiovascular disease (ASCVD). The two most common CHIP mutations are ten eleven translocase 2 (TET2) and DNA methyltransferase 3A (DNMT3A). However, there is limited data on specific cardiovascular phenotypes in this population. Methods: We recruited patients from the Vanderbilt University Medical Center cardiac catheterization laboratory and performed next generation sequencing to assign CHIP status. Multivariable logistic regression models and proportional odds models were used to assess the association between CHIP status and coronary angiography. Results: We sequenced 1,469 patients, and 1,149 had complete angiographic data. Of these, 214 (18.6%) had CHIP mutations with a variant allele frequency of &gt;2%. CHIP patients were significantly older (68 vs. 59 years, p = 7.7 x 10-16). CHIP carrier status was significantly correlated with any stenosis and degree of stenosis in the left main (LM) coronary artery (OR 1.87 [1.28-2.74]; P = 0.0013 and OR 2.12 [1.42-3.15]; P = 2.2 x 10-4). This association was stronger among patients with TET2 CHIP, both for any LM stenosis (OR 2.98 [1.48 - 5.96]; P = 0.0021) and the degree of LM stenosis (OR 3.52 [1.78 - 6.95]; P = 2.9 x 10-4) (Fig. 1). TET2 CHIP was also correlated with obstructive (&gt;70%) stenosis in any vessel (OR 2.28 [1.15 - 4.52]; P = 0.019), and the number of obstructive stenoses across coronary vessels (OR 1.83 [1.04 - 3.23]; P = 0.037). Conclusions: This is the first description of a specific atherosclerotic phenotype in CHIP and serves as a basis for understanding enhanced morbidity and mortality in CHIP. Our findings reveal a population enriched for CHIP carriers in the catheterization laboratory, an important observation for future studies focused on secondary prevention in CHIP-related ASCVD.

Absence of Coronary Artery Disease is a Strong Negative Predictor of Major Adverse Cardiovascular Events in Patients with Chronic Kidney Disease.

To investigate the interplay between chronic kidney disease (CKD) and coronary artery disease (CAD) on the incidence of cardiovascular events in patients with suspected chronic coronary syndrome (CCS). Patients with suspected CCS who underwent first-time coronary angiography in Western Denmark between 2003 and 2016 were included in this cohort study. Moreover, an age- and sex-matched general population cohort was established. Patients were stratified according to estimated glomerular filtration rate (eGFR). Presence of CAD was defined as ≥1 obstructive stenosis or non-obstructive diffuse disease. Major adverse cardiovascular events (MACE) were defined as a composite of myocardial infarction, ischemic stroke, and cardiac death. A total of 42,611 patients were included with a median follow-up of 7.3 years. Patients without and with CAD had MACE rates per 100 person-years that were 0.52 and 1.67 for eGFR ≥90 mL/min/1.73 m2, 0.68 and 2.09 for eGFR 60-89 mL/min/1.73 m2, 1.27 and 3.85 for eGFR 30-59 mL/min/1.73 m2, and 2.27 and 6.92 for eGFR <30 mL/min/1.73 m2. Comparing to eGFR ≥90 mL/min/1.73 m2, the adjusted incidence rate ratios for MACE were 1.29 (1.10-1.51) for eGFR 60-89 mL/min/1.73 m2, 1.86 (1.49-2.33) for eGFR 30-59 mL/min/1.73 m2, and 3.57 (1.92-6.67) for eGFR <30 mL/min/1.73 m2 in patients without CAD, and 1.11 (1.03-1.20), 1.71 (1.55-1.90), and 2.46 (1.96-3.09) in patients with CAD. The inverse relationship between kidney function and risk of MACE was confirmed when comparing patients with and without CAD to matched individuals in the general population. Absence of CAD is a strong negative predictor of major adverse cardiovascular events in patients with CKD.

On-site CT-derived cFFR in patients with suspected coronary artery disease: Feasibility on a 128-row CT scanner in everyday clinical practice.

Technical feasibility of CT-based calculation of fractional flow reserve (cFFR) using a 128-row computed tomography scanner in an everyday routine setting. Post-processing and everyday practicability should be analyzed on the scanner on-site in connection with clinical parameters. This single-center retrospective analysis included 230 patients (74 female; mean age 63.8years) with CCTA within 21 months between 01/2018 and 09/2019 without non-pathological examinations. cFFR values were obtained using a deep learning-based non-commercial research prototype (cFFR Version3.5.0; Siemens Healthineers GmbH, Erlangen). cFFR values were evaluated at two points: at the maximum point of the stenosis and 1.0 cm distal to the stenosis. Comparison with invasive coronary angiography in 57/230 patients (24.7 %) was performed. CT parameters and quality were evaluated. Further subgroup classification concerning criteria of technical postprocessing was performed: no changes necessary, minor corrections necessary, major corrections necessary, and no evaluation was possible. The required time from starting the software to the final result was evaluated. A total of 116/448 (25.9 %) mild, 223/448 (49.8 %) moderate, and 109/448 (24.3 %) obstructive stenoses was found. The mean cFFR at the maximum point of the stenosis was 0.92 ± 0.09 and significantly higher than the cFRR value of 0.89 ± 0.13 distal to the stenosis (p < 0.001*). The mean degree of stenosis was 44.02 ± 26.99 % (range: 1-99 %) with an area of 5.39 ± 3.30 mm2. In a total of 45 patients (19.1 %), a relevant reduction in cFFR below 0.80 was determined. Overall, in 57/230 patients (24.8 %), catheter angiography was performed. No significant difference in the degree of maximal stenosis (CAD-RADS 0-2/3/4) was detected between the classification of CCTA and ICA (p = 0.171). The mean post-processing time varied significantly with 8.34 ± 4.66 min. in single-vessel CAD vs. 12.91 ± 3.92 min. in two-vessel CAD vs. 21.80 ± 5.94 min. in three-vessel CAD (each p < 0.001). Noninvasive onsite quantification of cFFR is feasible with minimal observer interaction in a routine real-world setting on a 128-row scanner. Deep learning-based algorithms allow a robust and semi-automatic on-site determination of cFFR based on data from standard CT scanners. · Non-invasive on-site quantification of cFFR is feasible with minimal observer interaction.. · Deep-learning based algorithms allow robust and semi-automatic on-site determination of cFFR.. · The mean follow-up time varied significantly with the extent of vascular CAD..