Noninvasive Evaluation With Multislice Computed Tomography in Suspected Acute Coronary Syndrome Plaque Morphology on Multislice Computed Tomography Versus Coronary Calcium Score

ObjectivesOur aim was to evaluate the atherosclerotic plaque burden and morphology as determined by 64-slice multislice computed tomography (MSCT) coronary angiography in relation to the calcium score in patients presenting with suspected acute coronary syndrome (ACS).BackgroundThe absence of coronary calcium during coronary calcium scoring has been proposed to rule out significant coronary artery disease (CAD). However, data in patients presenting with suspected ACS are scarce.MethodsIn 40 patients (age 57 ± 11 years, 26 men) presenting with suspected ACS, MSCT coronary angiography in combination with coronary calcium scoring was performed before conventional coronary angiography. MSCT angiograms were evaluated for the presence or absence of coronary atherosclerotic plaque and the presence or absence of obstructive (≥50% luminal narrowing) CAD. In addition, plaque type was determined, and findings were related to the calcium score.ResultsCoronary artery disease was observed in 38 patients, of whom 10 patients had nonobstructive and 28 patients had obstructive CAD, confirmed by conventional coronary angiography in all patients. In patients with CAD, plaques were distributed as follows: 39% noncalcified plaques, 47% mixed plaques, and 14% calcified plaques. Coronary calcium was detected in 27 patients, of whom 10 had a score >400. In 13 (33%) patients, no coronary calcium was observed, but in 11 (85%), atherosclerotic plaques were detected on MSCT angiography.ConclusionsIn patients presenting with suspected ACS, noncalcified plaques are highly prevalent and the absence of coronary calcium does not reliably exclude the presence of (significant) atherosclerosis. This information may be of value to improve our understanding of the potential role of MSCT in this patient population

The value of multi-slice-computed tomography coronary angiography for risk stratification

Multi-slice-computed tomography coronary angiography (CTA) provides direct non-invasive anatomic assessment of the coronary arteries allowing for early identification of coronary artery disease (CAD). This information is useful for diagnosis of CAD, particularly the rule out of CAD. In addition, early identification of CAD with CTA may also be useful for risk stratification. The purpose of this review is to provide an overview of the current literature on the prognostic value of CTA and to discuss how the prognostic information obtained with CTA can be used to further integrate the technique into clinical practice. Non-invasive anatomic assessment of plaque burden, location, composition, and remodeling using CTA may provide prognostically relevant information. This information has been shown to be incremental to the Framingham risk score, coronary artery calcium scoring, and myocardial perfusion imaging. Characterization of atherosclerosis non-invasively has the potential to provide important prognostic information enabling a more patient-tailored approach to disease management. Future studies assessing outcome after CTA-based risk adjustments are needed to further understand the value of detailed non-invasive anatomic imaging

Influence of smoking on the prognostic value of cardiovascular computed tomography coronary angiography

Aims Computed tomography coronary angiography (CTA) is an important non-invasive imaging modality increasingly used for the diagnosis and prognosis of coronary artery disease (CAD). The purpose of the current study was to determine the influence of smoking status on the prognostic value of CTA in patients with suspected or known CAD. Methods and results In 1207 patients (57% male, age 57 ± 12 years) referred for CTA, the presence of significant CAD (≥50% stenosis) was determined. During follow-up (FU) the following events were recorded: all cause mortality, and non-fatal infarction. The prognostic value of CTA in smokers and non-smokers was compared using an interaction term in the Cox proportional hazard regression analysis. Significant CAD was observed in 327 patients (27%), and 273 patients (23%) were smokers. During a median FU time of 2.2 years, an event occurred in 50 patients. After correction for baseline characteristics including smoking in a multivariate model, significant CAD remained an independent predictor of events. Furthermore, a significant interaction (P < 0.05) was observed between significant CAD and smoking. The annualized event rate in smokers with significant CAD was 8.78% compared with 0.99% in smokers without significant CAD (P < 0.001). In non-smokers with significant CAD the annualized event rate was 2.07% compared with 1.01% in non-smokers without significant CAD (P= 0.058). Conclusion The prognostic value of CTA was significantly influenced by smoking status. The event rates in patients with significant CAD were approximately four-fold higher in smokers compared with non-smokers. These findings suggest that smoking cessation needs to be aggressively pursued, especially in smokers with significant CA

Incremental prognostic value of multi-slice computed tomography coronary angiography over coronary artery calcium scoring in patients with suspected coronary artery disease

Aims The purpose of this study was to assess the relationship between calcium scoring (CS) and multi-slice computed tomography coronary angiography (MSCTA) and to determine if MSCTA has an incremental prognostic value to CS. Methods and results In 432 patients (59% male, age 58 ± 11 years) referred for cardiac evaluation owing to suspected coronary artery disease (CAD), CS and 64-slice MSCTA were performed. The following events were combined in a composite endpoint: all-cause mortality, non-fatal infarction, and unstable angina requiring revascularization. CS was 0 in 147 (34%) patients, CS 1-99 was present in 122 (28%), CS 100-399 in 75 (17%), CS 400-999 in 56 (13%), and CS ≥ 1000 in 32 (7%). MSCTA was normal in 133 (31%) patients, MSCTA 30-50% stenosis was observed in 190 (44%), and MSCTA ≥50% stenosis in 109 (25%). During follow-up [median 670 days (25th-75th percentile: 418-895)], an event occurred in 21 patients (4.9%). After multivariate correction for CS, MSCTA ≥ 50% stenosis, the number of diseased segments, obstructive segments, and non-calcified plaques were independent predictors with an incremental prognostic value to CS. Conclusion MSCTA provides additional information to CS regarding stenosis severity and plaque composition. This additional information was shown to translate into incremental prognostic value over C

Prognostic value of coronary vessel dominance in relation to significant coronary artery disease determined with non-invasive computed tomography coronary angiography

Aims Limited information is available regarding the relationship between coronary vessel dominance and prognosis. Therefore, the purpose of this study was to determine the prognostic value of coronary vessel dominance in relation to significant coronary artery disease (CAD) in patients referred for computed tomography coronary angiography (CTA). Methods and results The study population consisted of 1425 patients (869 men, 57 ± 12 years) referred for CTA. To evaluate the impact of vessel dominance and significant CAD on CTA on outcome, patients were followed during a median period of 24 months for the occurrence of non-fatal myocardial infarction and all-cause mortality. The presence of a left dominant system was identified as a significant predictor for non-fatal myocardial infarction and all-cause mortality (HR: 3.20; 95% CI: 1.67-6.13, P < 0.001) and had incremental value over baseline risk factors and severity of CAD on CTA. In addition, in the subgroup of patients with significant CAD on CTA, patients with a left dominant system had a worse outcome compared with patients with a right dominant system (cumulative event rates: 9.5% and 35% at 3-year follow-up for a right and left dominant coronary artery system, respectively, log-rank P < 0.001). Conclusions The presence of a left dominant system was identified as an independent predictor of non-fatal myocardial infarction and all-cause mortality, especially in patients with significant CAD on CTA. Therefore, the assessment of coronary vessel dominance on CTA may further enhance risk stratification beyond the assessment of significant CAD on CT