-
1.
Coronary artery calcium: A technical argument for a new scoring method.
Willemink, MJ, van der Werf, NR, Nieman, K, Greuter, MJW, Koweek, LM, Fleischmann, D
Journal of cardiovascular computed tomography. 2019;(6):347-352
Abstract
Coronary artery calcium (CAC) is a strong predictor for future cardiovascular events. Traditionally CAC has been quantified using the Agatston score, which was developed in the late 1980s for electron beam tomography (EBT). While EBT has been completely replaced by modern multiple-detector row CT technology, the traditional CAC scoring method by Agatston remains in use, although the literature indicates suboptimal reproducibility and subjects being incorrectly classified. The traditional Agatston scoring method counteracts the technical advances of CT technology, and prevents the use of thinner sections, obtained at lower tube voltage and overall decreased radiation exposure that has become available to other CT applications. Moreover, recent studies have shown that not only the total amount of CAC, but also its density and distribution in the coronary arterial tree may be of prognostic value. Acquisition and reconstruction techniques thus need to be adapted for modern CT technology and optimized for CAC quantification. In this review we describe the technical limitations of the Agatston score followed by our suggestions for developing a new and more robust CAC quantification method.
-
2.
Intracoronary Lithotripsy for the Treatment of Calcified Plaque.
Yeoh, J, Hill, J
Interventional cardiology clinics. 2019;(4):411-424
Abstract
Intravascular lithotripsy facilitates percutaneous coronary intervention of lesions with severe calcification by using high-pressure ultrasonic energy. It is the newest adjunctive tool for calcium modification and is showing promise as its users gather more experience and it becomes readily available worldwide. This article reviews intravascular lithotripsy technology, the evidence in the literature, and the advantages and disadvantages compared with other forms of calcium modification, and discusses its role in specific subsets of coronary lesions. It concludes with a discussion about the future direction of research involving this new technology as its role within percutaneous cardiac procedures becomes more defined.
-
3.
Comparison of the vessel healing process after everolimus-eluting stent and bare metal stent implantations in patients with ST-elevation myocardial infarction.
Yano, H, Horinaka, S, Watahik, M, Watanabe, T, Ishimitsu, T
Heart and vessels. 2019;(4):572-582
Abstract
Cobalt-chromium everolimus-eluting stent (CoCr EES) is associated with a lower rate of stent thrombosis even in patients with ST-elevation myocardial infarction (STEMI). However, the time-serial changes of endothelial coverage of the stent struts in the extremely early period have never been reported, especially in patients with STEMI. The aim of this study was to compare the vessel healing process between CoCr EES and cobalt-chromium bare metal stent (CoCr BMS) implantations using optical coherence tomography (OCT) in patients with STEMI. Sixty-three patients who had primary emergent percutaneous coronary intervention (PCI) with CoCr EES (42 patients) or CoCr BMS (21 patients) were enrolled in this study for 3 years. OCT was performed just after, 2 and 12 weeks after EES or BMS implantations. Time-serial changes in the neointimal coverage (NIC), the neointimal thickness, and malapposition of stent struts were evaluated. NIC of stent struts did not differ between CoCr EES (23.2%, 99.4%) and CoCr BMS (24.0%, 97.8%) at 2 weeks and 12 weeks after PCI, respectively. Thicknesses of the neointima on the stent strut was significantly thinner in CoCr EES (34.0 ± 13.8, 107.0 ± 32.4 µm) than in CoCr BMS (40.0 ± 14.6, 115.7 ± 33.8 µm) at 2 weeks and 12 weeks after PCI (p = 0.011, p = 0.008), respectively. The malapposition did not differ just after PCI, and was completely resolved at 12 weeks after PCI in both groups. Thrombus was significantly less in CoCr EES than in CoCr BMS at 2 weeks (19.0% vs 42.9%, p < 0.01), and decreased over time in both groups, but at 12 weeks, disappeared only in CoCr EES (CoCr EES: 0% vs. CoCr BMS: 4.8%, p = 0.56). This study demonstrated that NIC and apposition of the stent struts almost completed at 12 weeks after EES and BMS implantations, while the neointimal thickness on the stent struts were thinner in EES than in BMS. Moreover, thrombus was significantly less in EES than in BMS implantations 2 weeks after PCI, which may explain the lower rate of acute and subacute stent thrombosis of EES compared with BMS.
-
4.
Cardiovascular Risk Heterogeneity in Adults with Diabetes: Selective Use of Coronary Artery Calcium in Statin Use Decision-making.
Sarkar, S, Orimoloye, OA, Nass, CM, Blumenthal, RS, Martin, SS
Journal of general internal medicine. 2019;(11):2643-2647
-
-
Free full text
-
Abstract
Current American College of Cardiology/American Heart Association and American Diabetes Association guidelines recommend statin therapy for all patients with diabetes between the ages of 40 and 75, including those without cardiovascular disease (CVD). While diabetes is a major CVD risk factor, not all patients with diabetes have an equal risk of CVD. Thus, a more risk-based approach warrants consideration when recommending statin therapy for the primary prevention of CVD. Coronary artery calcium (CAC) is a noninvasive imaging modality that can help risk stratify patients with diabetes for future CVD events. CAC has been extensively studied in large cohorts such as the Multi-Ethnic Study of Atherosclerosis and found to outperform other novel risk stratification tools including carotid intima-media thickness. Moreover, a CAC score of 0 has been shown to be useful in downgrading the estimated risk of a CVD event in patients with diabetes and an intermediate Pooled Cohort Equation score. As clinicians weigh the recommendation for a lifelong therapy and the problem of statin nonadherence and patients weigh concerns about adverse effects of statins, the decision to initiate statin therapy in patients with diabetes is ideally a shared one between patients and providers, and CAC could facilitate this discussion.
-
5.
Low short-term and long-term cardiovascular and all-cause mortality in absence of coronary artery calcium: A 22-year follow-up observational study from large cohort.
Shaikh, K, Li, D, Nakanishi, R, Kinninger, A, Almeida, S, Cherukuri, L, Shekar, C, Roy, SK, Birudaraju, D, Rai, K, et al
Journal of diabetes and its complications. 2019;(9):616-622
Abstract
OBJECTIVES We sought to evaluate the gender-specific predictive value of coronary artery calcium (CAC) score on all-cause mortality and cardiovascular disease (CVD) mortality in individuals with and without diabetes mellitus (DM). BACKGROUND CAC score is a robust predictor of CVD and all-cause mortality during long-term follow-up in large cohorts in adults with DM. However, less is known about its sex-specific impact on all-cause mortality in DM. METHODS We evaluated 25,563 asymptomatic participants with no known history of coronary artery disease (CAD) who underwent clinically indicated CAC. 1999 (7.8%) individuals had diabetes. CAC was characterized as an Agatston score of 0, 1-99, 100-300, and ≫300. We evaluated the association between CAC and all-cause mortality and CVD mortality. RESULTS Overall, 1345 individuals died (5.3%) from all causes during a mean follow-up of 14.7 ± 3.8 years. CAC score was 0 in 57.5% females and 34.4% of males without DM, while 36.6% females and 20.3% males with DM had CAC-0. The frequency of CAC ≫ 300 was 18% and 36% in females and males with DM, respectively. CAC score of zero was associated with low all-cause mortality event rate in females and males with diabetes (1.7 and 2.5 events per 1000 person-years, respectively). Cardiovascular mortality per 1000 person years was ≪1 in females and males with CAC score of 0 irrespective of their diabetes. Adjusted multivariable analysis, compared to CAC-0, HR for all-cause mortality associated with CAC 1-99, 100-299 and ≫300 were 1.74(95% CI 0.65, 4.63, P-0.20), 5.54(95% CI 2.16, 14.22, P ≪ 0.001) and 5.75(95% CI 2.30, 14.37, P ≪ 0.001) in females with DM respectively; in males with DM HR associated with CAC 1-99, 100-299 and ≫300 were 1.87(95% CI 0.95, 3.66, P-0.06), 2.15(95% CI 1.05, 4.38, P-0.035) and 2.60(95% CI 1.34, 5.0, P-0.004), respectively. CONCLUSION Presence of subclinical atherosclerosis varies among individuals with DM. The absence of CAC was associated with very low cardiovascular as well as all-cause mortality events in all subgroups during long term follow-up.
-
6.
Multicentre, open-label, randomised controlled clinical trial to assess the efficacy and safety of appropriate target values for lipid management in patients who have mild-to-moderate stenotic lesions with high-risk plaques in coronary arteries: study protocol.
Matsuda, M, Kada, A, Saito, AM, Hasegawa, K
BMJ open. 2019;(1):e022843
Abstract
INTRODUCTION To detect patients at high risk of developing myocardial infarction, plaque characteristics as well as the degree of stenosis in coronary arteries should be evaluated. However, unstable plaque or severe calcification detected via coronary artery CT (CACT) is not reflected in risk stratification according to current guidelines. It is hypothesised that patients with high-risk findings on CACT (even those without proven history of coronary artery diseases; CAD) should be strictly managed to lower their low-density lipoprotein cholesterol (LDL-C) levels to targets of secondary prevention. Currently, however, there is no evidence based on prospective randomised intervention studies to prove this hypothesis. METHODS AND ANALYSIS Patients with mild-to-moderate stenotic lesions with positive remodelling or severe calcification, but without any history of CAD, will be randomly allocated to group A (reduce LDL-C to <120~160 mg/dL according to the primary prevention criteria based on the Japan Atherosclerosis Society (JAS) Guideline for Prevention of Atherosclerotic Cardiovascular Diseases 2017) and group B (reduce LDL-C to <70 mg/dL according to the secondary prevention criteria for high risk based on the JAS Guideline). They will be strictly managed to achieve the LDL-C targets. We will follow-up and evaluate the composite endpoints consisting of major cardiovascular events (death from CAD, non-fatal myocardial infarction, operation for coronary revascularisation and stroke) and stenosis progression or new stenosis development for 3 years. ETHICS AND DISSEMINATION The study was approved by the National Hospital Organization Central Research Ethics Committee. The results of this study are scheduled to be published within 2 years after study completion via conference presentation or journal publication. TRIAL REGISTRATION NUMBER UMIN000031136.
-
7.
Effect of cutting balloon after rotational atherectomy in severely calcified coronary artery lesions as assessed by optical coherence tomography.
Amemiya, K, Yamamoto, MH, Maehara, A, Oyama, Y, Igawa, W, Ono, M, Kido, T, Ebara, S, Okabe, T, Yamashita, K, et al
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions. 2019;(7):936-944
Abstract
OBJECTIVES Using optical coherence tomography (OCT), we evaluated the effect of a cutting balloon (CB) compared with a conventional balloon after rotational atherectomy (RA) and before stenting in severely calcified coronary lesions. BACKGROUND A CB is designed to create discrete incisions to facilitate fracture of severely calcified plaque. METHODS OCT was performed preintervention (if possible), post-RA, and poststent implantation. RA modification of calcium was defined as a polished, concave, round-shaped surface. Calcium fracture was defined as a break in the calcium plate. The effects of calcium modification and stent expansion between CB (n = 18) versus conventional balloon (n = 23) following RA were compared. RESULTS Median patient age was 72 years with 24% on hemodialysis. The amount of calcium and the length of RA modification were comparable between the CB and conventional balloon groups. Final poststent OCT showed that the number and thickness of calcium fracture were greater after CB versus conventional balloon, resulting better stent expansion (78.9% [IQR: 72.4-88.1] vs. 66.7% [IQR: 55.0-76.7], p < 0.01). In the multivariable model, after adjusting for the amount of calcium, CB use was an independent predictor of the presence of calcium fracture (odds ratio 30.0; 95% confidence interval 2.7-994.1, p = 0.004) and an independent predictor for greater stent expansion (regression coefficient 7.4; 95% confidence interval 0.5-14.3, p = 0.04). CONCLUSION In severely calcified lesions calcium fracture was more often associated with RA followed by CB compared with RA followed by conventional balloon predilation before stenting. CB use was also a determinant of greater stent expansion.
-
8.
Cut-off value of mal-apposition volume and depth for resolution at early phase of acute incomplete stent apposition after CoCr-EES implantation.
Uchimura, Y, Itoh, T, Oda, H, Taguchi, Y, Sasaki, W, Kaneko, K, Sakamoto, T, Goto, I, Sakuma, M, Ishida, M, et al
The international journal of cardiovascular imaging. 2019;(11):1979-1987
Abstract
The purpose of this study was to clarify a cut-off value for acute incomplete stent apposition (ISA) volume and maximum-depth to predict ISA resolution at 1- and 3-month follow-up in patients treated with cobalt-chromium everolimus-eluting stents. In total, 95 cases and 103 stents were registered in the MECHANISM-Elective sub-study. Acute ISA-volume was measured by the trapezoid rule. ISA resolution of cut-off value at 1- and 3-month was estimated by ISA-volume and maximum-depth using receiver operatorating characteristic curve analysis. The total number of analysed acute ISAs was 202 in the 1-month group and 225 in the 3-month group. A total of 123 ISAs at 1-month and a total of 169 ISAs at 3-month had been resolved. The cut-off value of ISA resolution by ISA-volume was 0.169 mm3 at 1-month (AUC: 0.725, sensitivity: 72.2%, specificity: 61.0%) and 0.295 mm3 at 3-month (AUC: 0.757, sensitivity: 75.0%, specificity: 60.4%). The cut-off value of ISA resolution by ISA maximum-depth demonstrated was 0.285 mm at 1-month (area under curve (AUC): 0.789, sensitivity: 70.9%, specificity: 69.9%) and 0.305 mm at 3-month (AUC: 0.663, sensitivity: 60.7%, specificity: 66.9%). Incidence of ISA resolution was significantly lower in combination with cut-off values of ISA-volume and maximum-depth (33%, p < 0.001, at 1-month; 56%, p = 0.003, at 3-month). Combining the cut-off value of ISA-volume with the maximum-depth might be helpful to consider the endpoint of the PCI procedure.
-
9.
Effect of orbital atherectomy in calcified coronary artery lesions as assessed by optical coherence tomography.
Yamamoto, MH, Maehara, A, Kim, SS, Koyama, K, Kim, SY, Ishida, M, Fujino, A, Haag, ES, Alexandru, D, Jeremias, A, et al
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions. 2019;(7):1211-1218
Abstract
OBJECTIVES We sought to assess plaque modification and stent expansion following orbital atherectomy (OA) for calcified lesions using optical coherence tomography (OCT). BACKGROUND The efficacy of OA for treating calcified lesions is not well studied, especially using intravascular imaging in vivo. METHODS OCT was performed preprocedure, post-OA, and post-stent (n = 58). Calcium modification after OA was defined as a round, concave, polished calcium surface. Calcium fracture was complete discontinuity of calcium. RESULTS Comparing pre- vs post-OA OCT (n = 29), calcium area was significantly decreased post-OA (from 3.4 mm2 [2.4-4.7] to 2.9 mm2 [1.9-3.9], P < 0.001). Poststent percent calcium fracture (calcium fracture length/calcium length) correlated with post-OA percent calcium modification (calcium modification length/calcium length) (r = 0.31, P = 0.01). Among 75 calcium fractures in 35 lesions, maximum calcium thickness at the fracture site was greater with vs without calcium modification (0.58 mm [0.50-0.66] vs 0.45 mm [0.38-0.52], P = 0.003). Final optimal stent expansion, defined as minimum stent area ≥6.1 mm2 or stent expansion ≥90% (medians of this cohort) at the maximum calcium angle site, was observed in 41 lesions. Larger post-OA lumen area (odds ratio 2.64; 95% CI 1.21-5.76; P = 0.02) and the presence of calcium fracture (odds ratio 6.77; 95% CI 1.25-36.6; P = 0.03) were independent predictors for optimal stent expansion. CONCLUSIONS Calcium modification by OA facilitates poststent calcium fracture even in thick calcium. Greater calcium modification correlated with greater calcium fracture, in turn resulting in better stent expansion.
-
10.
Impact of iodine concentration and iodine delivery rate on contrast enhancement in coronary CT angiography: a randomized multicenter trial (CT-CON).
Rengo, M, Dharampal, A, Lubbers, M, Kock, M, Wildberger, JE, Das, M, Niezen, A, van Tilborg, F, Kofflard, M, Laghi, A, et al
European radiology. 2019;(11):6109-6118
Abstract
OBJECTIVE To compare the effect of contrast medium iodine concentration on contrast enhancement, heart rate, and injection pressure when injected at a constant iodine delivery rate in coronary CT angiography (CTA). METHODS One thousand twenty-four patients scheduled for coronary CTA were prospectively randomized to receive one of four contrast media: iopromide 300 mg I/ml, iohexol 350 mg I/ml, iopromide 370 mg I/ml, or iomeprol 400 mg I/ml. Contrast media were delivered at an equivalent iodine delivery rate of 2.0 g I/s. Intracoronary attenuation was measured and compared (per vessel and per segment). Heart rate before and after contrast media injection was documented. Injection pressure was recorded (n = 403) during contrast medium injection and compared between groups. RESULTS Intracoronary attenuation values were similar for the different contrast groups. The mean attenuation over all segments ranged between 384 HU for 350 mg I/ml and 395 HU for 400 mg I/ml (p = 0.079). Dose-length product (p = 0.8424), signal-to-noise ratio (all p > 0.05), time to peak (p = 0.324), and changes in heart rate (p = 0.974) were comparable between groups. The peak pressures differed: 197.4 psi for 300 mg I/ml (viscosity 4.6 mPa s), 229.8 psi for 350 mg I/ml (10.4 mPa s), 216.1 psi for 370 mg I/ml (9.5 mPa s), and 243.7 psi for 400 mg I/ml (12.6 mPa s) (p < 0.0001). CONCLUSION Intravascular attenuation and changes in heart rate are independent of iodine concentration when contrast media are injected at the same iodine delivery rate. Differences in injection pressures are associated with the viscosity of the contrast media. KEY POINTS • The contrast enhancement in coronary CT angiography is independent of the iodine concentration when contrast media are injected at body temperature (37 °C) with the same iodine delivery rate. • Iodine concentration does not influence the change in heart rate when contrast media are injected at identical iodine delivery rates. • For a fixed iodine delivery rate and contrast temperature, the viscosity of the contrast medium affects the injection pressure.