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      Coronary Artery Plaque Characteristics Associated With Adverse Outcomes in the SCOT-HEART Study

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          Abstract

          Background

          Unlike most noninvasive imaging modalities, coronary computed tomography angiography can characterize subtypes of atherosclerotic plaque.

          Objectives

          The purpose of this study was to investigate the prognostic implications of adverse coronary plaque characteristics in patients with suspected coronary artery disease.

          Methods

          In this SCOT-HEART (Scottish COmputed Tomography of the HEART Trial) post hoc analysis, the presence of adverse plaque (positive remodeling or low attenuation plaque), obstructive disease, and coronary artery calcification within 15 coronary segments was assessed on coronary computed tomography angiography of 1,769 patients who were followed-up for 5 years.

          Results

          Among study participants (mean age 58 ± 10 years; 56% male), 608 (34%) patients had 1 or more adverse plaque features. Coronary heart disease death or nonfatal myocardial infarction was 3 times more frequent in patients with adverse plaque (n = 25 of 608 [4.1%] vs. n = 16 of 1,161 [1.4%]; p < 0.001; hazard ratio [HR]: 3.01; 95% confidence interval (CI): 1.61 to 5.63; p = 0.001) and was twice as frequent in those with obstructive disease (n = 22 of 452 [4.9%] vs. n = 16 of 671 [2.4%]; p = 0.024; HR: 1.99; 95% CI: 1.05 to 3.79; p = 0.036). Patients with both obstructive disease and adverse plaque had the highest event rate, with a 10-fold increase in coronary heart disease death or nonfatal myocardial infarction compared with patients with normal coronary arteries (HR: 11.50; 95% CI: 3.39 to 39.04; p < 0.001). However, these associations were not independent of coronary artery calcium score, a surrogate measure of coronary plaque burden.

          Conclusions

          Adverse coronary plaque characteristics and overall calcified plaque burden confer an increased risk of coronary heart disease death or nonfatal myocardial infarction. (Scottish COmputed Tomography of the HEART Trial [SCOT-HEART]; NCT01149590)

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          Multislice computed tomographic characteristics of coronary lesions in acute coronary syndromes.

          Renu Virmani, Yukio Ozaki, Kaori Inoue … (2007)
          To evaluate the feasibility of noninvasive assessment of the characteristics of disrupted atherosclerotic plaques, the authors interrogated the culprit lesions in acute coronary syndromes (ACS) by multislice computed tomography (CT). Disrupted atherosclerotic plaques responsible for ACS histopathologically demonstrate large lipid cores and positive vascular remodeling. It is expected that plaques vulnerable to rupture should bear similar imaging signatures by CT. Either 0.5-mm x 16-slice or 64-slice CT was performed in 38 patients with ACS and compared with 33 patients with stable angina pectoris (SAP) before percutaneous coronary intervention. The coronary plaques in ACS and SAP were evaluated for the CT plaque characteristics, including vessel remodeling, consistency of noncalcified plaque (NCP <30 HU or 30 HU
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            Coronary Atherosclerotic Precursors of Acute Coronary Syndromes

            Hyung-Bok Park, Daniel Berman, Matthew Budoff … (2018)
            Background The association of atherosclerotic features with first acute coronary syndromes (ACS) has not accounted for plaque burden. Objectives To identify atherosclerotic features associated with precursors of ACS. Methods We performed a nested case:control study within a cohort of 25,251 patients undergoing coronary computed tomographic angiography (CCTA) with follow-up over 3.4±2.1 years. ACS patients and non-events with no prior coronary artery disease (CAD) were propensity matched 1:1 for risk factors and CCTA-evaluated obstructive (≥50%) CAD. Separate core labs performed blinded adjudication of ACS and culprit lesions and quantification of baseline CCTA for % diameter stenosis (%DS), % cross-sectional plaque burden (PB), plaque volumes (PV) by composition (calcified, fibrous, fibro-fatty, and necrotic core), and presence of high-risk plaques (HRP). Results We identified 234 ACS and control pairs (62 years, 63% male). Over 65% of ACS patients had non-obstructive CAD at baseline, and 52% had HRP. %DS, cross-sectional PB, fibro-fatty and necrotic core volume, and HRP increased the adjusted hazard ratio (HR) of ACS [1.010 per %DS, 95% confidence interval (CI) 1.005–1.015; 1.008 per % cross-sectional PB, 95% CI 1.003–1.013; 1.002 per mm 3 fibro-fatty plaque, 95% CI 1.000–1.003; 1.593 per mm 3 necrotic core, 95%CI 1.219–2.082; all p <0.05]. Of the 129 culprit lesion precursors identified by CCTA, three-fourths exhibited <50% stenosis and 31.0% exhibited HRP. Conclusion Although ACS increases with %DS, most precursors of ACS cases and culprit lesions are non-obstructive. Plaque evaluation, including HRP, PB, and plaque composition, identifies high risk patients above and beyond stenosis severity and aggregate plaque burden.
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              Prognostic Value of Coronary Artery Calcium in the PROMISE Study (Prospective Multicenter Imaging Study for Evaluation of Chest Pain)

              Matthew Budoff, Thomas Mayrhofer, Maros Ferencik … (2017)
              Background Coronary artery calcium (CAC) is an established predictor of future major adverse atherosclerotic cardiovascular events in asymptomatic individuals. However limited data exist as to how CAC compares to functional testing (FT) in estimating prognosis in symptomatic patients. Methods In the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial, patients with stable chest pain (or dyspnea) and intermediate pre-test probability for obstructive coronary artery disease (CAD) were randomized to FT (exercise electrocardiography, nuclear stress, or stress echocardiography) or anatomic testing. We evaluated those who underwent CAC testing as part of the anatomic evaluation (n=4,209) and compared to results of FT (n=4,602). We stratified CAC and FT results as normal or mildly, moderately or severely abnormal (for CAC: 0, 1–99 Agatston Score [AS], 100–400 AS and >400 AS, respectively; for FT: normal, mild=late positive treadmill, moderate=early positive treadmill or single-vessel ischemia and severe=large ischemic region abnormality). The primary endpoint was all-cause death, myocardial infarction or unstable angina hospitalization over a median follow-up of 26.1 months. Cox regression models were used to calculate hazard ratios and C-statistic to determine predictive and discriminatory value. Results Overall, the distribution of normal or mildly, moderately or severely abnormal test results was significantly different between FT and CAC (FT = normal 3588 [78.0%], mild 432 [9.4%], moderate 217 [4.7%], severe 365 [7.9%]; CAC = normal 1,457 [34.6%], mild 1340 [31.8%], moderate 772 [18.3%], severe 640 [15.2%], p <0.0001). Moderate and severe abnormalities in both arms robustly predicted events (moderate: CAC HR 3.14, 95% CI 1.81–5.44 and FT HR 2.65, 95% CI 1.46–4.83; severe: CAC HR 3.56, 95% CI 1.99–6.36 and FT HR 3.88, 95% CI 2.58–5.85. In the CAC arm, the majority of events (n=112/133; 84%) occurred in patients with any positive CAC test (score >0) whereas less than half of events occurred in patients with mild, moderate or severely abnormal FT (n=57/132; 43%) (p<0.001). In contrast, any abnormality on FT was significantly more specific for predicting events (78.6% for FT vs 35.2% for CAC, p<0.001). Overall discriminatory ability in predicting the primary endpoint of mortality, nonfatal myocardial infarction, and unstable angina hospitalization was similar and fair for both CAC and FT (c-statistic, 0.67 vs. 0.64). Coronary computed tomographic angiography provided significantly better prognostic information compared to FT and CAC testing (C-index: 0.72). Conclusion Among stable outpatients presenting with suspected CAD, most patients experiencing clinical events have measurable CAC at baseline while less than half have any abnormalities on FT. However, an abnormal FT was more specific for cardiovascular events, leading to overall similarly modest discriminatory abilities of both tests. Clinical Trial Registration URL: https://clinicaltrials.gov ; Unique Identifier: NCT01174550
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                Author and article information

                Contributors
                Michelle C. Williams
                Journal
                Journal ID (nlm-ta): J Am Coll Cardiol
                Journal ID (iso-abbrev): J. Am. Coll. Cardiol
                Title: Journal of the American College of Cardiology
                Publisher: Elsevier Biomedical
                ISSN (Print): 0735-1097
                ISSN (Electronic): 1558-3597
                Publication date PMC-release: 29 January 2019
                Publication date (Print): 29 January 2019
                Volume: 73
                Issue: 3
                Pages: 291-301
                Affiliations
                [a ]University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom
                [b ]Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, United Kingdom
                [c ]Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
                [d ]University of Cambridge School of Clinical Medicine, Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
                [e ]Institute of Clinical Sciences, University of Glasgow, Glasgow, United Kingdom
                [f ]Royal Brompton and Harefield NHS Foundation Trust Departments of Cardiology and Radiology, London, United Kingdom
                [g ]National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, United Kingdom
                Author notes
                [∗ ] Address for correspondence: Dr. Michelle C. Williams, University of Edinburgh/BHF Centre for Cardiovascular Science, Chancellor’s Building, SU305, 49 Little France Crescent, Edinburgh EH1 6SUF, United Kingdom. michelle.williams@ 123456ed.ac.uk @ 123456imagingmedsci
                Article
                Publisher ID: S0735-1097(18)39210-6
                DOI: 10.1016/j.jacc.2018.10.066
                PMC ID: 6342893
                PubMed ID: 30678759
                SO-VID: 522e49d4-7f5d-40f6-a83b-d3d6d381bc58
                Copyright © © 2019 The Authors
                License:

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                Date received : 27 December 2017
                Date revision received : 15 October 2018
                Date accepted : 16 October 2018
                Categories
                Subject: Article

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: atherosclerotic plaque,computed tomography,coronary angiography,coronary artery disease,au, agatston units,ci, confidence interval,ct, computed tomography,cta, computed tomography angiography,hr, hazard ratio,iqr, interquartile range
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: atherosclerotic plaque, computed tomography, coronary angiography, coronary artery disease, au, agatston units, ci, confidence interval, ct, computed tomography, cta, computed tomography angiography, hr, hazard ratio, iqr, interquartile range

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