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Coronary plaque volume and predictors for fast plaque progression assessed by serial coronary CT angiography-A single-center observational study.
Weber, C, Deseive, S, Brim, G, Stocker, TJ, Broersen, A, Kitslaar, P, Martinoff, S, Massberg, S, Hadamitzky, M, Hausleiter, J
European journal of radiology. 2020;:108805
Abstract
PURPOSE The rationale of this study was to identify patients with fast progression of coronary plaque volume PV and characterize changes in PV and plaque components over time. METHOD Total PV (TPV) was measured in 350 patients undergoing serial coronary computed tomography angiography (median scan interval 3.6 years) using semi-automated software. Plaque morphology was assessed based on attenuation values and stratified into calcified, fibrous, fibrous-fatty and low-attenuation PV for volumetric measurements. Every plaque was additionally classified as either calcified, partially calcified or non-calcified. RESULTS In total, 812 and 955 plaques were detected in the first and second scan. Mean TPV increase was 20 % on a per-patient base (51.3 mm³ [interquartile range (IQR): 14.4, 126.7] vs. 61.6 mm³ [IQR: 16.7, 170.0]). TPV increase was driven by calcified PV (first scan: 7.6 mm³ [IQR: 0.2, 33.6] vs. second scan: 16.6 mm³ [IQR: 1.8, 62.1], p < 0.01). Forty-two patients showed fast progression of TPV, defined as >1.3 mm3 increase of TPV per month. Male sex (odds ratio 3.1, p = 0.02) and typical angina (odds ratio 3.95, p = 0.03) were identified as risk factors for fast TPV progression, while high-density lipoprotein cholesterol had a protective effect (odds ratio per 10 mg/dl increase of HDL cholesterol: 0.72, p < 0.01). Progression to >50 % stenosis at follow-up was observed in 34 of 327 (10.4 %) calcified plaques, in 13 of 401 (3.2 %) partially calcified plaques and 2 of 221 (0.9 %) non-calcified plaques (p < 0.01). CONCLUSION Fast plaque progression was observed in male patients and patients with typical angina. High HDL cholesterol showed a protective effect.
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Postsystolic shortening on echocardiography as a gateway to cardiac computed tomography in patients with suspected stable angina pectoris.
Brainin, P, Olsen, FJ, Lassen, MCH, Bech, J, Claggett, B, Fritz-Hansen, T, Folke, F, Gislason, GH, Biering-Sørensen, T
The international journal of cardiovascular imaging. 2020;(2):309-316
Abstract
Postsystolic shortening (PSS) by speckle-tracking echocardiography (STE) is a marker of myocardial ischemia and may improve diagnostic strategy. We sought to evaluate if PSS is associated with the coronary artery calcium score (CACS) and stenosis by computed tomography angiography (CTA) in patients with suspected stable angina pectoris (SAP). We retrospectively studied 437 SAP patients (age 58 ± 11 years, 41% male) who underwent STE, evaluation of CACS and assessment of significant stenosis (≥ 50%) by CTA. The postsystolic index (PSI) was defined as follows: 100x([peak negative strain cardiac cycle - peak negative strain systole])/peak negative strain cardiac cycle. A wall had PSS if any segment within the wall had a PSI ≥ 20%. We defined categories for walls with PSS: 0, 1, 2 and ≥ 3, and CACS 0, 1-100, 101-400 and > 400. Each additional wall with PSS was associated with a 43% relative increase in CACS (95%CI +9% to +87%, P = 0.010), while each 1% absolute increase in the PSI was associated with a 9% relative increase in CACS (95%CI +1% to +18%, P = 0.031). Walls with PSS (OR 1.81 per 1 wall increase, 95%CI 1.27-2.59, P = 0.001) and the PSI (OR 1.12 per 1% increase, 95%CI 1.04-1.21, P = 0.004) were associated with the occurrence of CACS > 400. Additionally, walls with PSS (OR 1.53 per 1 wall increase, 95%CI 1.21-1.93, P < 0.001) was a predictor of significant stenosis by CTA. PSS is associated with CACS and significant stenosis by CTA in patients with SAP and may aid in the selection of patients referred for cardiac computed tomography.
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Increased Serum Malondialdehyde-Modified Low-Density Lipoprotein and Coronary Angiographic Progression After Drug-Eluting Stent Implantation in Patients With Stable Angina.
Yokoi, M, Ito, T, Fujita, H, Sugiura, T, Seo, Y, Ohte, N
Circulation journal : official journal of the Japanese Circulation Society. 2020;(10):1837-1845
Abstract
BACKGROUND Cardiac events can occur after drug-eluting stent (DES) implantation due to coronary plaque progression at non-stented sites. Malondialdehyde-modified low-density lipoprotein (MDA-LDL) is suggested to be an atherogenic marker. This study investigated the relationship between serum MDA-LDL and angiographic progression after DES implantation.Methods and Results:In total, 207 patients who underwent percutaneous coronary intervention (PCI) using DES and follow-up coronary angiography were retrospectively analyzed. MDA-LDL was serially measured before PCI and at follow up. Persistent high MDA-LDL was defined as a MDA-LDL level more than the median value both before PCI and at follow up. Angiographic progression was assessed by serial analysis of quantitative coronary angiography. Angiographic progression occurred in 35 patients (16.9%). MDA-LDL before PCI was significantly higher in the progression group than the non-progression group in all patients (143.4±35.8 U/L vs. 103.0±33.5U/L, P<0.001) and in patients with controlled LDL-cholesterol (LDL-C <100 mg/dL both before PCI and at follow up; 121.8±32.7 U/L vs. 84.9±24.9 U/L, P<0.001). There were positive correlations between % diameter stenosis changes and serum MDA-LDL before PCI in all patients (r=0.33, P<0.01) and those with controlled LDL-C (r=0.23, P=0.04). In multivariate logistic regression analysis, persistent high MDA-LDL was an independent predictor of plaque progression. CONCLUSIONS Increased serum MDA-LDL was associated with angiographic progression after DES implantation.
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Machine learning of clinical variables and coronary artery calcium scoring for the prediction of obstructive coronary artery disease on coronary computed tomography angiography: analysis from the CONFIRM registry.
Al'Aref, SJ, Maliakal, G, Singh, G, van Rosendael, AR, Ma, X, Xu, Z, Alawamlh, OAH, Lee, B, Pandey, M, Achenbach, S, et al
European heart journal. 2020;(3):359-367
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Abstract
AIMS: Symptom-based pretest probability scores that estimate the likelihood of obstructive coronary artery disease (CAD) in stable chest pain have moderate accuracy. We sought to develop a machine learning (ML) model, utilizing clinical factors and the coronary artery calcium score (CACS), to predict the presence of obstructive CAD on coronary computed tomography angiography (CCTA). METHODS AND RESULTS The study screened 35 281 participants enrolled in the CONFIRM registry, who underwent ≥64 detector row CCTA evaluation because of either suspected or previously established CAD. A boosted ensemble algorithm (XGBoost) was used, with data split into a training set (80%) on which 10-fold cross-validation was done and a test set (20%). Performance was assessed of the (1) ML model (using 25 clinical and demographic features), (2) ML + CACS, (3) CAD consortium clinical score, (4) CAD consortium clinical score + CACS, and (5) updated Diamond-Forrester (UDF) score. The study population comprised of 13 054 patients, of whom 2380 (18.2%) had obstructive CAD (≥50% stenosis). Machine learning with CACS produced the best performance [area under the curve (AUC) of 0.881] compared with ML alone (AUC of 0.773), CAD consortium clinical score (AUC of 0.734), and with CACS (AUC of 0.866) and UDF (AUC of 0.682), P < 0.05 for all comparisons. CACS, age, and gender were the highest ranking features. CONCLUSION A ML model incorporating clinical features in addition to CACS can accurately estimate the pretest likelihood of obstructive CAD on CCTA. In clinical practice, the utilization of such an approach could improve risk stratification and help guide downstream management.
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Evaluation of an AI-based, automatic coronary artery calcium scoring software.
Sandstedt, M, Henriksson, L, Janzon, M, Nyberg, G, Engvall, J, De Geer, J, Alfredsson, J, Persson, A
European radiology. 2020;(3):1671-1678
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OBJECTIVES To evaluate an artificial intelligence (AI)-based, automatic coronary artery calcium (CAC) scoring software, using a semi-automatic software as a reference. METHODS This observational study included 315 consecutive, non-contrast-enhanced calcium scoring computed tomography (CSCT) scans. A semi-automatic and an automatic software obtained the Agatston score (AS), the volume score (VS), the mass score (MS), and the number of calcified coronary lesions. Semi-automatic and automatic analysis time were registered, including a manual double-check of the automatic results. Statistical analyses were Spearman's rank correlation coefficient (⍴), intra-class correlation (ICC), Bland Altman plots, weighted kappa analysis (κ), and Wilcoxon signed-rank test. RESULTS The correlation and agreement for the AS, VS, and MS were ⍴ = 0.935, 0.932, 0.934 (p < 0.001), and ICC = 0.996, 0.996, 0.991, respectively (p < 0.001). The correlation and agreement for the number of calcified lesions were ⍴ = 0.903 and ICC = 0.977 (p < 0.001), respectively. The Bland Altman mean difference and 1.96 SD upper and lower limits of agreements for the AS, VS, and MS were - 8.2 (- 115.1 to 98.2), - 7.4 (- 93.9 to 79.1), and - 3.8 (- 33.6 to 25.9), respectively. Agreement in risk category assignment was 89.5% and κ = 0.919 (p < 0.001). The median time for the semi-automatic and automatic method was 59 s (IQR 35-100) and 36 s (IQR 29-49), respectively (p < 0.001). CONCLUSIONS There was an excellent correlation and agreement between the automatic software and the semi-automatic software for three CAC scores and the number of calcified lesions. Risk category classification was accurate but showing an overestimation bias tendency. Also, the automatic method was less time-demanding. KEY POINTS • Coronary artery calcium (CAC) scoring is an excellent candidate for artificial intelligence (AI) development in a clinical setting. • An AI-based, automatic software obtained CAC scores with excellent correlation and agreement compared with a conventional method but was less time-consuming.
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The Predictive Value of Coronary Artery Calcium Scoring for Major Adverse Cardiac Events According to Renal Function (from the Coronary Computed Tomography Angiography Evaluation for Clinical Outcomes: An International Multicenter [CONFIRM] Registry).
Lee, JH, Rizvi, A, Hartaigh, BÓ, Han, D, Park, MW, Roudsari, HM, Stuijfzand, WJ, Gransar, H, Lu, Y, Callister, TQ, et al
The American journal of cardiology. 2019;(9):1435-1442
Abstract
The prognostic performance of coronary artery calcium score (CACS) for predicting adverse outcomes in patients with decreased renal function remains unclear. We aimed to examine whether CACS improves risk stratification by demonstrating incremental value beyond a traditional risk score according to renal function status. 9,563 individuals without known coronary artery disease were enrolled. Estimated glomerular filtration rate (eGFR, ml/min/1.73 m2) was ascertained using the modified Modification of Diet in Renal Disease formula, and was categorized as: ≥90, 60 to 89, and <60. CACS was categorized as 0, 1 to 100, 101 to 400, and >400. Multivariable Cox regression was used to estimate hazard ratios (HR) with 95% confidence intervals (95% CI) for major adverse cardiac events (MACE), comprising all-cause mortality, myocardial infarction, and late revascularization (>90 days). Mean age was 55.8 ± 11.5 years (52.8% male). In total, 261 (2.7%) patients experienced MACE over a median follow-up of 24.5 months (interquartile range: 16.9 to 41.1). Incident MACE increased with higher CACS across each eGFR category, with the highest rate observed among patients with CACS >400 and eGFR <60 (95.1 per 1,000 person-years). A CACS >400 increased MACE risk with HR 4.46 (95% CI 1.68 to 11.85), 6.63 (95% CI 4.03 to 10.92), and 6.14 (95% CI 2.85 to 13.21) for eGFR ≥90, 60 to 89, and <60, respectively, as compared with CACS 0. Further, CACS improved discrimination and reclassification beyond Framingham 10-year risk score (FRS) (AUC: 0.70 vs 0.64; category free-NRI: 0.51, all p <0.001) for predicting MACE in patients with impaired renal function (eGFR < 90). In conclusion, CACS improved risk stratification and provided incremental value beyond FRS for predicting MACE, irrespective of eGFR status.
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Epicardial Fat Volume Improves the Prediction of Obstructive Coronary Artery Disease Above Traditional Risk Factors and Coronary Calcium Score.
Zhou, J, Chen, Y, Zhang, Y, Wang, H, Tan, Y, Liu, Y, Huang, L, Zhang, H, Ma, Y, Cong, H
Circulation. Cardiovascular imaging. 2019;(1):e008002
Abstract
BACKGROUND Recent studies have demonstrated the tremendous potential of epicardial fat volume (EFV) to predict obstructive coronary artery disease. We aimed to develop a new model to estimate pretest probability of obstructive coronary artery disease using traditional risk factors with coronary calcium score and EFV and compare it with proposed models in Chinese patients who underwent coronary computed tomography angiography. METHODS The new models were derived from 5743 consecutive patients using multivariate logistic regression and validated in an internal cohort using invasive coronary angiography as the outcome and an external cohort with clinical outcome data. Hosmer-Lemeshow goodness-of-fit test, area under the receiver operating characteristic curve, integrated discrimination improvement and net reclassification improvement were calculated to validate and compare the performance of models. RESULTS EFV improved prediction above conventional risk factors and coronary calcium score (area under the receiver operating characteristic curve increased from 0.856 to 0.874, integrated discrimination improvement 0.0487, net reclassification improvement 0.1181, P<0.0001 for all). The final model included 5 predictors: age, sex, symptom, coronary calcium score, and EFV. Good internal validation and external validation of the new model were achieved, with positive net reclassification improvement and integrated discrimination improvement, excellent area under the receiver operating characteristic curve and favorable calibration. Further, the new model demonstrated a better prediction of clinical outcome, resulting in a more cost-effective risk stratification to optimize decision-making of downstream diagnosis and treatment. CONCLUSIONS Addition of EFV to conventional risk factors and coronary calcium score offered a more accurate and effective estimation for pretest probability of obstructive coronary artery disease, which may help to improve initial management of stable chest pain.
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Risk Reclassification With Coronary Computed Tomography Angiography-Visualized Nonobstructive Coronary Artery Disease According to 2018 American College of Cardiology/American Heart Association Cholesterol Guidelines (from the Coronary Computed Tomography Angiography Evaluation for Clinical Outcomes : An International Multicenter Registry [CONFIRM]).
Han, D, Beecy, A, Anchouche, K, Gransar, H, Dunham, PC, Lee, JH, Achenbach, S, Al-Mallah, MH, Andreini, D, Berman, DS, et al
The American journal of cardiology. 2019;(9):1397-1405
Abstract
The 2018 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol management guideline recommends risk enhancers in the borderline-risk and statin recommended/intermediate-risk groups. We determined the risk reclassification by the presence and severity of coronary computed tomography angiography (CCTA)-visualized coronary artery disease (CAD) according to statin eligibility groups. Of 35,281 individuals who underwent CCTA, 1,303 asymptomatic patients (age 59, 65% male) were identified. Patients were categorized as low risk, borderline risk, statin recommended/intermediate risk or statin recommended/high risk according to the guideline. CCTA-visualized CAD was categorized as no CAD, nonobstructive, or obstructive. Major adverse cardiovascular events (MACE) were defined as a composite outcome of all-cause mortality, nonfatal myocardial infarction, and late coronary revascularization (>90 days). We tested a reclassification wherein no CAD reclassifies downward, and the presence of any CAD reclassifies upward. During a median follow-up of 2.9 years, 93 MACE events (7.1%) were observed. Among the borderline-risk and statin-recommended/intermediate-risk groups eligible for risk enhancers, the presence or absence of any CCTA-visualized CAD led to a net increase of 2.3% of cases and 22.4% of controls correctly classified (net reclassification index [NRI] 0.27, 95% CI 0.13 to 0.41, p = 0.0002). The NRI was not significant among low- or statin-recommended/high-risk patients (all p >0.05). The presence or absence of CCTA-visualized CAD, including both obstructive and nonobstructive CAD, significantly improves reclassification in patients eligible for risk enhancers in 2018 ACC/AHA guidelines. Patients in low- and high-risk groups derive no significant improvement in risk reclassification from CCTA.
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Coronary computed tomography angiography and echocardiography in children with homozygous familial hypercholesterolemia.
Luirink, IK, Kuipers, IM, Hutten, BA, Planken, RN, Backx, APCM, Groothoff, JW, Wiegman, A
Atherosclerosis. 2019;:87-92
Abstract
BACKGROUND AND AIMS Homozygous familial hypercholesterolemia (hoFH) is a rare genetic disease, hallmarked by a lifelong exposure to very high levels of low-density lipoprotein cholesterol (LDL-C). Untreated, patients can experience a cardiovascular event in the first decade of life. Early detection and monitoring of subclinical atherosclerosis in these patients is therefore extremely important. We set out to assess the diagnostic yield of low-dose coronary computed tomography angiography (cCTA) compared to echocardiography in detecting subclinical atherosclerosis. METHODS For this single-center cross-sectional study, we included all pediatric hoFH patients treated with lipoprotein-apheresis (LA) in Amsterdam UMC. We performed both cCTA and echocardiography in all patients as part of routine follow-up. RESULTS Six hoFH patients were included. Median ages at diagnosis, onset of LA and cardiovascular assessment (cCTA and echocardiography) were 2.6, 6.5, 10.8 and 11.1 years, respectively. Echocardiography revealed no signs of atherosclerosis in any of the six patients. In two patients, mild dilatation of the cardiac chambers was detected and two patients showed signs of mitral or aortic insufficiency. On cCTA, however, non-calcified plaques without stenosis were detected in four patients. In two patients calcified coronary plaques were found at the ostia of the right coronary artery or the left main coronary artery. Aortic root calcifications were found in two patients. CONCLUSIONS Our findings suggest that in hoFH children, low-dose cCTA is superior to echocardiography for the detection of subclinical coronary and aortic root atherosclerosis and should therefore be considered in the routine cardiovascular monitoring of these high-risk children.
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Intraplaque neovascularization attenuated statin benefit on atherosclerotic plaque in CAD patients: A follow-up study with combined imaging modalities.
Liu, X, Sun, C, Gu, X, Liu, X, Wang, X, Wang, X, Xie, Z, Tian, J, Yu, B
Atherosclerosis. 2019;:134-139
Abstract
BACKGROUND AND AIMS Plaque progression increases the risk of a cardiovascular event. This study aims to determine whether intraplaque neovascularization (NV) associates with a greater risk of plaque progression. METHODS Baseline and 12-month follow-up IVUS was used in combination with baseline OCT to assess 164 non-culprit plaques in 118 CAD patients. A generalized estimating equation approach with exchangeable correlation structure was used to correct for the dependency of repeated measurements. RESULTS Patients were divided into two groups according to NV (52 patients with 62 NV plaques, 66 patients with 102 non-NV plaques). Non-culprit plaques in the NV group exhibited a more frequent occurrence of TCFA (p = 0.004), macrophage (p = 0.005), cholesterol crystal (p = 0.012), calcification (p = 0.030), thinner fibrous cap thickness (FCT) [(86.8 ± 55.1) vs. (127.4 ± 70.1) μm, p = 0.015], larger lipid arc [(219.5 ± 66.9) vs. (179.8 ± 61.4), p = 0.002] compared to the non-NV group. A large change in percent atheroma volume (PAV), plaque plus media cross-sectional area (P&M CSA), plaque volume, and plaque burden was observed from baseline to follow-up in the NV group. Changes in P&M CSA, plaque volume, and plaque burden showed significant differences in fibroatheroma with NV. Intraplaque NV could predict a high risk of plaque progression despite statin therapy [OR 6.521 (95% CI 2.457-17.308), p < 0.001]. CONCLUSIONS NV might attenuate the benefits of statin therapy in plaque progression. This study may provide a new basis for anti-angiogenic strategies to prevent atherosclerotic plaque progression.