Coronary Artery Plaque Burden Nomograms

HomeCirculation: Cardiovascular ImagingVol. 10, No. 3Coronary Artery Plaque Burden Nomograms Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBCoronary Artery Plaque Burden NomogramsAre They Ready for Use? Paolo Raggi, MD and Nikolaos Alexopoulos, MD Paolo RaggiPaolo Raggi From the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.); and Euroclinic Athens, SA, Athens, Greece (N.A.). and Nikolaos AlexopoulosNikolaos Alexopoulos From the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (P.R.); and Euroclinic Athens, SA, Athens, Greece (N.A.). Originally published14 Mar 2017https://doi.org/10.1161/CIRCIMAGING.117.006187Circulation: Cardiovascular Imaging. 2017;10:e006187Coronary computed tomography angiography (CCTA) is frequently used in symptomatic patients to exclude the presence of obstructive coronary artery disease. Beyond high diagnostic accuracy, it provides valuable prognostic information. There is accumulating evidence that a patient's risk of major adverse events is not solely due to the presence of obstructive coronary artery disease but also to the presence of nonobstructive atherosclerotic disease. In this light, CCTA has a definite advantage over invasive angiography because it provides information on plaque volume and composition beyond luminal stenosis.1 Currently, CCTA is the only noninvasive method available in everyday clinical practice capable of providing such information.See Article by Naoum et alSeveral reports on the prognostic value of CCTA demonstrated a stepwise increase in the risk of events from absence of coronary atherosclerosis, to presence of nonobstructive atherosclerosis, to obstructive coronary artery disease.2–4 It would seem, therefore, that CCTA provides confirmation of the tenet that the burden of atherosclerosis is prognostically significant beyond the presence of obstructive luminal disease. In this issue of Circulation: Cardiovascular Imaging, Naoum et al5 report on a new approach to risk stratification of patients referred to CCTA based on a proportional assessment of the burden of atherosclerosis accumulated in the coronary artery tree. After developing a simple quantification score based on the number of coronary segments showing atherosclerosis involvement (the segment involvement score [SIS]), the authors derived nomograms of SIS among ≈11 000 men and 9700 women referred for CCTA in the CONFIRM-I study (Coronary CT Angiography Evaluation For Clinical Outcomes International Multicenter). These patients represented the derivation cohort and provided an initial test of the utility of the SIS nomograms to predict major adverse cardiovascular events or death. The authors then tested the same concept in a validation cohort of ≈3000 patients from the CONFIRM phase II study. In both groups, the event rates were statistically higher in patients above the 50th and 75th SIS percentile (SIS%) compared with those below the 50th percentile. While death and major adverse cardiovascular events were predicted by SIS% in the derivation cohort, only major adverse cardiovascular events were predicted by SIS% in the validation cohort. Women demonstrated a higher hazard of events than men when their SIS was above the 75th percentile both in the derivation and the validation cohort. Naturally, the event rate increased with increasing age and SIS%. The effort made by the investigators resembles closely the quantification of coronary atherosclerosis on noncontrast computed tomography with coronary artery calcium (CAC) score percentiles.6 The latter were introduced in an attempt to explain the occurrence of events in patients with an apparent low absolute CAC score.6 While validated by others, MESA (Multi-Ethnic Study of Atherosclerosis) investigators found the absolute CAC scores to be of greater prognostic value then the CAC percentiles.7The report by Naoum et al5 provides a novel and simple tool to assess risk of coronary events in patients submitted to CCTA, and as such it represents a useful and welcome innovation. Furthermore, it highlights the importance of the burden of atherosclerosis in women where despite less severe luminal stenosis than in men, the outcome of atherosclerotic heart disease is often worse. In a seminal report, Vaccarino et al8 demonstrated that this is chiefly true for women in young age. In this group, therefore, the SIS% may be particularly useful given the low incidence of obstructive luminal disease.There are, however, a few notable limitations in this report. CCTA is not a test that can be performed in the population at large and is limited for the most part to patients with symptoms or with a high-risk profile. In the current study, 53% of the patients in the derivation cohort had a 10-year Framingham risk score over 10%, and 65% were symptomatic. In this light, the SIS% failed to bring more clarity to the pursuit of the Holy Grail: how to identify vulnerable patients among the general population where the majority of events are bound to occur. For this purpose, CAC screening remains the best screening tool at this time.9While SIS% is easy to obtain and it does not seem to be too time-consuming, the clear identification of noncalcified plaques, especially if small, may be difficult in the presence of motion artifacts that blur the image. In spite of its simplicity, the SIS% does not take into direct consideration the presence of obstructive disease of the left main or proximal left anterior descending coronary artery that are well-known predictors of severe adverse outcomes. Additionally, other features of plaque vulnerability, such as a large noncalcified core and positive vessel wall remodeling as described by Otsuka et al,10 are not included in the SIS% method of risk assessment.Despite these limitations, SIS% seems to be a promising tool for the assessment of risk in patients undergoing CCTA. Further studies will ascertain its ease of applicability to everyday clinical practice and will likely compare its prognostic value with that of other imaging modalities and risk scores. In light of these results, one has to wonder whether the adverse prognosis associated with an abnormal myocardial perfusion study is caused by the presence of a large atherosclerosis burden rather than by myocardial ischemia per se, and a future study may need to challenge such notion. Meanwhile, it is a pleasure to see how the field of CCTA continues to expand in the hands of inventive and dedicated researchers.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Paolo Raggi, MD, Mazankowski Alberta Heart Institute, University of Alberta, 4A7.050, 8440–112 St, Edmonton, AB T6G 2B7, Canada. E-mail [email protected]References1. Motoyama S, Sarai M, Harigaya H, Anno H, Inoue K, Hara T, Naruse H, Ishii J, Hishida H, Wong ND, Virmani R, Kondo T, Ozaki Y, Narula J. Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute coronary syndrome.J Am Coll Cardiol. 2009; 54:49–57. doi: 10.1016/j.jacc.2009.02.068.CrossrefMedlineGoogle Scholar2. Bittencourt MS, Hulten E, Ghoshhajra B, O'Leary D, Christman MP, Montana P, Truong QA, Steigner M, Murthy VL, Rybicki FJ, Nasir K, Gowdak LH, Hainer J, Brady TJ, Di Carli MF, Hoffmann U, Abbara S, Blankstein R. Prognostic value of nonobstructive and obstructive coronary artery disease detected by coronary computed tomography angiography to identify cardiovascular events.Circ Cardiovasc Imaging. 2014; 7:282–291. doi: 10.1161/CIRCIMAGING.113.001047.LinkGoogle Scholar3. Min JK, Shaw LJ, Devereux RB, Okin PM, Weinsaft JW, Russo DJ, Lippolis NJ, Berman DS, Callister TQ. 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Predictive value of age-and sex-specific nomograms of global plaque burden on coronary computed tomography angiography for major cardiac events.Circ Cardiovasc Imaging. 2017; 10:e004896. doi: 10.1161/CIRCIMAGING.116.004896.LinkGoogle Scholar6. Raggi P, Callister TQ, Cooil B, He ZX, Lippolis NJ, Russo DJ, Zelinger A, Mahmarian JJ. Identification of patients at increased risk of first unheralded acute myocardial infarction by electron-beam computed tomography.Circulation. 2000; 101:850–855.LinkGoogle Scholar7. Budoff MJ, Nasir K, McClelland RL, Detrano R, Wong N, Blumenthal RS, Kondos G, Kronmal RA. Coronary calcium predicts events better with absolute calcium scores than age-sex-race/ethnicity percentiles: MESA (Multi-Ethnic Study of Atherosclerosis).J Am Coll Cardiol. 2009; 53:345–352. doi: 10.1016/j.jacc.2008.07.072.CrossrefMedlineGoogle Scholar8. Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants.N Engl J Med. 1999; 341:217–225. doi: 10.1056/NEJM199907223410401.CrossrefMedlineGoogle Scholar9. Polonsky TS, McClelland RL, Jorgensen NW, Bild DE, Burke GL, Guerci AD, Greenland P. Coronary artery calcium score and risk classification for coronary heart disease prediction.JAMA. 2010; 303:1610–1616. doi: 10.1001/jama.2010.461.CrossrefMedlineGoogle Scholar10. Otsuka K, Fukuda S, Tanaka A, Nakanishi K, Taguchi H, Yoshikawa J, Shimada K, Yoshiyama M. Napkin-ring sign on coronary CT angiography for the prediction of acute coronary syndrome.JACC Cardiovasc Imaging. 2013; 6:448–457. doi: 10.1016/j.jcmg.2012.09.016.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails March 2017Vol 10, Issue 3 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.117.006187PMID: 28292864 Originally publishedMarch 14, 2017 Keywordscomputed tomography angiographyEditorialsmyocardial revascularizationpredictionmyocardial infarctiondeathPDF download Advertisement SubjectsComputerized Tomography (CT)Diagnostic Testing

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