Coronary Artery Calcium Score-Weighted Clinical Likelihood Model Performance in Patients with Stable Chest Pain and Coronary Artery Calcium Scores of Zero.

Background: For individuals with persistent stable chest pain (SCP) and a coronary artery calcium score (CACS) of 0, it might be challenging to establish the best risk assessment method for determining the individuals who will not benefit from further cardiovascular imaging testing (CIT). Thus, we investigated the CACS-weighted clinical likelihood (CACS-CL) model in SCP patients with a CACS of 0. Methods: Thus, to assess SCP, we originally enrolled 14,232 individuals for CACS and coronary computed tomography angiography (CCTA) scans between January 2016 and January 2018. Finally, patients with a CACS of 0 were included and followed up ​until January 2022. According to the established CACS-CL cutoffs of 15% and 5%, the associations between coronary artery disease (CAD) and major adverse cardiovascular events (MACEs) in risk groups were evaluated, alongside the net reclassification improvement (NRI). Results: Of the 6689 patients with a CACS of 0, the prevalence of CAD increased significantly (p < 0.0001) in patients with higher CACS-CL. However, there was no significant difference in the CAD distribution (p = 0.0637) between patients with CACS-CL < 5% and 5-15%. The association between the CACS-CL = 15%-determined risk groups and the occurrence of MACEs was stronger than for a CACS-CL = 5% (adjusted hazard ratio (HR): 7.24 (95% CI: 1.93-16.42) versus 3.68 (95% CI: 1.50-8.26)). Compared with the cutoff for CACS-CL = 5%, the NRI was 10.61% when using a cutoff for CACS-CL = 15%. Conclusions: Among patients with an SCP and CACS of 0, the CACS-CL model provided accurate predictions of CAD and MACEs. Compared to the cutoff for CACS-CL = 5%, the cutoff for CACS-CL = 15% seemed to be more effective and safer for deferring further CIT. Clinical Trial registration: NCT04691037.

Association between Coronary Artery Disease Reporting and Data System-recommended Post-Coronary CT Angiography Management and Clinical Outcomes in Patients with Stable Chest Pain from a Chinese Registry.

Background Coronary Artery Disease Reporting and Data System (CAD-RADS) was developed to standardize and optimize disease management in patients after coronary CT angiography (CCTA), but the impact of CAD-RADS management recommendations on clinical outcomes remains unclear. Purpose To retrospectively assess the association between the appropriateness of post-CCTA management according to CAD-RADS version 2.0 and clinical outcomes. Materials and Methods From January 2016 to January 2018, consecutive participants with stable chest pain referred for CCTA were prospectively included in a Chinese registry and followed for 4 years. Retrospectively, CAD-RADS 2.0 classification and the appropriateness of post-CCTA management were determined. Propensity score matching (PSM) was used to adjust for confounding variables. Hazard ratios (HRs) for a major adverse cardiovascular event (MACE), relative risks for invasive coronary angiography (ICA), and the corresponding number needed to treat were estimated. Results Of the 14 232 included participants (mean age, 61 years ± 13 [SD]; 8852 male), 2330, 2756, and 2614 were retrospectively categorized in CAD-RADS 1, 2, and 3, respectively. Only 26% of participants with CAD-RADS 1-2 disease and 20% with CAD-RADS 3 received appropriate post-CCTA management. After PSM, appropriate post-CCTA management was associated with lower risk of MACEs (HR, 0.34; 95% CI: 0.22, 0.51; P < .001), corresponding to a number needed to treat of 21 in CAD-RADS 1-2 but not CAD-RADS 3 (HR, 0.86; 95% CI: 0.49, 1.85; P = .42). Appropriate post-CCTA management was associated with decreased use of ICA in CAD-RADS 1-2 (relative risk, 0.40; 95% CI: 0.29, 0.55; P < .001) and 3 (relative risk, 0.33; 95% CI: 0.28, 0.39; P < .001), resulting in a number needed to treat of 14 and 2, respectively. Conclusion In this retrospective secondary analysis, appropriate disease management after CCTA according to CAD-RADS 2.0 was associated with lower risk of MACEs and more prudent use of ICA. ClinicalTrials.gov registration no. NCT04691037 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Leipsic and Tzimas in this issue.

Sex Differences in Two International Guidelines for Assessing Obstructive Coronary Artery Disease in Symptomatic Outpatients by Coronary Computed Tomographic Angiography.

Background: Low-risk individuals are unlikely to benefit from noninvasive testing, and women tend to have a lower prevalence of coronary artery disease (CAD). This study compared the performance of two current guidelines that differ by sex to assess s a'q's't chest pain outpatients, including symptom-based (2016 National Institute for Health and Care Excellence, NICE) and risk-based strategies (2019 European Society of Cardiology, ESC). Methods: A total of 542 outpatients referred for coronary computed tomography angiography (CCTA) at a single-centre were retrospectively included in this study. A risk assessment was calculated for each outpatient according to the two guidelines. Patients were classified into low and high-risk groups according to each strategy. The presence of coronary artery disease was the endpoint. Net reclassification improvement (NRI) was used to assess the performance of the two strategies. Results: The prevalence of CAD was 27%. The sensitivity, specificity, positive predictive value and negative predictive value for ESC and NICE were 90.4%, 54.3%, 42.2%, 93.9% and 78.8%, 35.6%, 31.1% and 82.0% respectively. Compare to NICE, the NRI for ESC were 30.32%. The ESC guidelines classified 55.56% of women and 28.14% of men into the low-risk group. The ESC guidelines had a higher predictive value for coronary artery disease compared to the NICE guidelines, with a positive NRI in men (15.55%) and women (34.46%) respectively. Conclusions: The ESC guidelines offered a more accurate calculation of risk assessment than the NICE guidelines. Patient sex influenced applying the recent ESC guidelines, which would result in a significant decrease in inappropriate testing of women but an increase in appropriate noninvasive testing of men.

Comparison of two diagnostic strategies for patients with stable chest pain suggestive of chronic coronary syndrome: rationale and design of the double-blind, pragmatic, randomized and controlled OPERATE Trial.

BACKGROUND: To achieve potential financial savings and avoid exposing the patients to unnecessary risk, an optimal diagnostic strategy to identify low risk individual who may derive minimal benefit from further cardiac imaging testing (CIT) is important for patients with stable chest pain (SCP) suggestive of chronic coronary syndrome (CCS). Although several diagnostic strategies have been recommended by the most recent guidelines, few randomized controlled trials (RCTs) have prospectively investigated the actual effect of applying these strategies in clinical practice. METHODS: OPERATE (OPtimal Evaluation of stable chest pain to Reduce unnecessAry utilization of cardiac imaging TEsting) trial is an investigator-initiated, multicenter, coronary computed tomography angiography (CCTA)-based, 2-arm parallel-group, double-blind, pragmatic and confirmative RCT planning to include 800 subjects with SCP suggestive of CCS. After enrollment, all subjects will be randomized to two arms (2016 U.K. National Institute of Health and Care Excellence guideline-determined and 2019 European Society of Cardiology guideline-determined diagnostic strategy) on a 1:1 basis. According to each strategy, CCTA should be referred and deferred for a subject in high and low risk group, respectively. The primary (effectiveness) endpoint is CCTA without obstructive coronary artery disease. Safety of each strategy will be mainly assessed by 1-year major adverse cardiovascular event rates. DISCUSSION: The OPERATE trial will provide comparative effectiveness and safety evidences for two different diagnostic strategies for patients with SCP suggestive of CCS, with the intension of improving the diagnostic yield of CCTA at no expense of safety. CLINICAL TRIAL REGISTRATION: ClinicalTrial.org Identifier NCT05640752.

Comparison of the RF-CL and CACS-CL models to estimate the pretest probability of obstructive coronary artery disease and predict prognosis in patients with stable chest pain and diabetes mellitus.

Background: The most appropriate tool for estimating the pretest probability (PTP) of obstructive coronary artery disease (CAD) in patients with diabetes mellitus (DM) and stable chest pain (SCP) remains unknown. Therefore, we aimed to validate and compare two recent models, namely, the risk factor-weighted clinical likelihood (RF-CL) model and coronary artery calcium score (CACS)-weighted clinical likelihood (CACS-CL) model, in these patient populations. Methods: A total of 1,245 symptomatic patients with DM, who underwent CACS and coronary computed tomographic angiography (CCTA) scan, were identified and followed up. PTP of obstructive CAD for each patient was estimated using the RF-CL model and CACS-CL model, respectively. Area under the receiver operating characteristic curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were used to assess the performance of models. The associations of major adverse cardiovascular events (MACE) with risk groups were evaluated using Cox proportional hazards regression. Results: Compared with the RF-CL model, the CACS-CL model revealed a larger AUC (0.856 vs. 0.782, p = 0.0016), positive IDI (12%, p < 0.0001) and NRI (34%, p < 0.0001), stronger association to MACE (hazard ratio: 0.26 vs. 0.38) and less discrepancy between observed and predicted probabilities, resulting in a more effective risk assessment to optimize downstream clinical management. Conclusion: Among patients with DM and SCP, the incorporation of CACS into the CACS-CL model resulted in a more accurate estimation for PTP and prediction of MACE. Utilizing the CACS-CL model, instead of the RF-CL model, might have greater potential to avoid unnecessary and omissive cardiovascular imaging testing with minimal cost.

Comparison of Different Investigation Strategies to Defer Cardiac Testing in Patients With Stable Chest Pain.

OBJECTIVES: This study aimed to compare the current 5 investigation strategies to defer cardiac testing in patients with stable chest pain. BACKGROUND: For the clinical management of stable chest pain, the identification of patients unlikely to benefit from further cardiac testing is important, but the most appropriate investigation strategy is unknown. METHODS: A total of 4,207 patients referred to coronary computed tomography angiography for stable chest pain were classified into low- and high-risk groups according to the 2016 National Institute of Health and Care Excellence (NICE) guideline-determined strategy; PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) minimal risk tool-based strategy; 2019 European Society of Cardiology (ESC) guideline-determined strategy; and coronary artery calcium score (CACS), either in isolation (the CACS strategy) or as part of a weighted clinical likelihood model-based strategy (the CACS-CL strategy). The associations of obstructive coronary artery disease on coronary computed tomography angiography, major adverse cardiovascular events, and subsequent clinical management with risk groups according to different strategies were evaluated and compared. RESULTS: The NICE, PROMISE, ESC, CACS, and CACS-CL strategies classified a proportion (22.63%, 29.21%, 41.84%, 46.76%, and 51.41%, respectively) of patients into low-risk groups. Compared with the NICE, PROMISE, ESC, and CACS strategies, the CACS-CL strategy had a stronger association between risk groups and obstructive coronary artery disease (odd ratios: 16.00 vs 2.93, 5.53, 7.94, and 10.39, respectively), major adverse cardiovascular events (HRs: 6.83 vs 1.90, 2.94, 4.23, and 5.13, respectively) and intensive subsequent clinical management as well as better metrics of diagnostic accuracy and positive net reclassification improvement. CONCLUSIONS: Among contemporary strategies used to identify patients with stable chest pain at low risk, the use of CACS, especially when combined with clinical risk features, showed the strongest potential to effectively defer cardiac testing.

Epicardial Fat Volume Improves the Prediction of Obstructive Coronary Artery Disease Above Traditional Risk Factors and Coronary Calcium Score.

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.

Epicardial adipose tissue is associated with high-risk plaque feature progression in non-culprit lesions.

Several studies have suggested a link between epicardial adipose tissue (EAT) volume and high-risk plaques (HRPs); however, little is known about the association between EAT volume and HRP progression in non-culprit lesions (NCLs). Therefore, we evaluated whether EAT can independently predict HRP characteristic progression in NCLs by coronary computed tomography angiography (CCTA). In this single-centre trial, we analysed 131 consecutive patients (median age 61 years, male 72.52%) undergoing CCTA with percutaneous coronary intervention (PCI) for culprit lesions. All patients were scheduled to undergo follow-up CCTA 12 months after PCI. HRP features, including positive remodelling, low attenuation plaque, spotty calcification, and napkin-ring sign, along with EAT volume, were assessed by CCTA. The numbers of HRP features were compared between baseline and follow-up CCTA to detect HRP progression in NCLs, and patients were classified into two groups based on HRP progression. Logistic regression analysis was used to evaluate whether EAT volume was independently associated with HRP progression in NCLs. Overall, 23 of 131 patients who underwent two CCTAs exhibited HRP progression in NCLs (17.6%). Logistic regression analysis showed that a higher baseline EAT volume was associated with NCL HRP progression (odds ratio 1.019, 95% confidence interval 1.009-1.029, P < 0.001). The cut-off value for baseline EAT volume for NCL HRP progression was 107 ml based on receiver-operator characteristic curve analyses, and the area under the curve was 0.66. Baseline EAT volume was identified as an independent predictor of NCL HRP progression.

Characteristics Detected on Computed Tomography Angiography Predict Coronary Artery Plaque Progression in Non-Culprit Lesions.

OBJECTIVE: This study sought to determine whether variables detected on coronary computed tomography angiography (CCTA) would predict plaque progression in non-culprit lesions (NCL). MATERIALS AND METHODS: In this single-center trial, we analyzed 103 consecutive patients who were undergoing CCTA and percutaneous coronary intervention (PCI) for culprit lesions. Follow-up CCTA was scheduled 12 months after the PCI, and all patients were followed for 3 years after their second CCTA examination. High-risk plaque features and epicardial adipose tissue (EAT) volume were assessed by CCTA. Each NCL stenosis grade was compared visually between two CCTA scans to detect plaque progression, and patients were stratified into two groups based on this. Logistic regression analysis was used to evaluate the factors that were independently associated with plaque progression in NCLs. Time-to-event curves were compared using the log-rank statistic. RESULTS: Overall, 34 of 103 patients exhibited NCL plaque progression (33%). Logistic regression analyses showed that the NCL progression was associated with a history of ST-elevated myocardial infarction (odds ratio [OR] = 5.855, 95% confidence interval [CI] = 1.391-24.635, p = 0.016), follow-up low-density lipoprotein cholesterol level (OR = 6.832, 95% CI = 2.103-22.200, p = 0.001), baseline low-attenuation plaque (OR = 7.311, 95% CI = 1.242-43.028, p = 0.028) and EAT (OR = 1.015, 95% CI = 1.000-1.029, p = 0.044). Following the second CCTA examination, major adverse cardiac events (MACEs) were observed in 12 patients, and NCL plaque progression was significantly associated with future MACEs (log rank p = 0.006). CONCLUSION: Noninvasive assessment of NCLs by CCTA has potential prognostic value.

Validation and comparison of four models to calculate pretest probability of obstructive coronary artery disease in a Chinese population: A coronary computed tomographic angiography study.

OBJECTIVE: We sought to compare the performance of the updated Diamond-Forrester method (UDFM), Duke clinical score (DCS), Genders clinical model (GCM) and Genders extended model (GEM) in a Chinese population referred to coronary computed tomography angiography (coronary CTA). BACKGROUND: The reliability of existing models to calculate the pretest proability (PTP) of obstructive coronary artery disease (CAD) have not been fully investigated, especially in a Chinese population. METHODS: We identified 5743 consecutive patients with suspected stable CAD who underwent coronary calcium scoring (CCS) and coronary CCTA. Obstructive CAD was defined as with the presence of ≥50% diameter stenosis in coronary CTA or unassessable segments due to severe calcification. Area under the receiver operating characteristic curve (AUC), integrated discrimination improvement (IDI), net reclassification improvement (NRI) and Hosmer-Lemeshow goodness-of-fit statistic (H-L χ2) were assessed to validate and compare these models. RESULTS: Overall, 1872 (32%) patients had obstructive CAD and 2467 (43%) had a CCS of 0. GEM demonstrated improved discrimination over the other models through the largest AUC (0.816 for GEM, 0.774 for GCM, 0.772 for DCS and 0.765 for UDFM). UDFM (-0.3255, p < 0.0001), DCS (-0.3149, p < 0.0001) and GCM (-0.2264, p < 0.0001) showed negative IDI compared to GEM. The NRI was significantly higher for GEM than the other models (0.7152, p < 0.0001, 0.5595, p < 0.0001 and 0.3195, p < 0.0001, respectively). All of the four models overestimated the prevalence of obstructive CAD, with unsatisfactory (p < 0.01 for all) calibration for UDFM (H-L χ2 = 137.82), DCS (H-L χ2 = 156.70), GCM (H-L χ2 = 51.17) and GEM (H-L χ2 = 29.67), respectively. CONCLUSION: Although GEM was superior for calculating PTP in a Chinese population referred for coronary CTA, developing new models allowing for more accurate and operational estimation are warranted.

Comparison of CT-RECTOR and J-CTO scores to predict chronic total occlusion difficulty for percutaneous coronary intervention.

BACKGROUND: We sought to evaluate the ability of the CT-RECTOR and J-CTO scores to predict time-efficient guidewire (GW) crossing through a chronic total occlusion (CTO) and final procedure success. METHODS: Data from 191 consecutive CTO lesions with pre-procedural coronary computed tomography angiography (CCTA) from our center were analyzed retrospectively. The difficulty of the procedure was classified as easy, intermediate, difficult, or very difficult according to CT-RECTOR and J-CTO scores. A successful GW crossing within 30min was set as the first endpoint. Final success of the procedure was set as the second endpoint. Receiver operating characteristic curves and net reclassification improvement (NRI) were used to compare the performance of both scores in predicting both endpoints. RESULTS: The first and second endpoints were achieved in 55% and 76% of lesions, respectively. The NRI for prediction for both endpoints were 30.21% and 28.94%, respectively. Use of the CT-RECTOR score demonstrated a positive NRI for both the first (p=0.0027) and second (p=0.0190) endpoints. Compared with the J-CTO score (area under the curve: 0.76), the CT-RECTOR score (area under the curve: 0.85) yielded a higher predictive value for successful GW crossing within 30min (p=0.0018). CONCLUSIONS: Compared with J-CTO, the CT-RECTOR scoring system provides a more accurate noninvasive tool for predicting time-efficient GW crossing and final procedure success. This scoring system, which is based on CCTA, may aid in the identification of very difficult CTO lesions and downstream management.

Influence of increased epicardial adipose tissue volume on 1-year in-stent restenosis in patients who received coronary stent implantation.

BACKGROUND: Epicardial adipose tissue (EAT) is significantly associated with the formation and composition of coronary atherosclerotic plaque, cardiac events and the clinical prognosis of coronary heart disease. But, whether increased EAT deposition may affect the incidence of in-stent restenosis (ISR) is currently unclear. This study used coronary computed tomography angiography (CCTA) as a mean to investigate whether increased EAT volume was associated with ISR. METHODS: A total of 364 patients who underwent 64-slice CCTA examination for the evaluation of suspected coronary artery disease, and subsequently underwent percutaneous coronary intervention (PCI) for the first time, and then accepted coronary angiography (CA) follow-up for ISR examination in one year, were retrospectively included in this study. EAT volume was measured by CCTA examination. CA follow-up was obtained between 9 and 15 months. ISR was defined as ≥ 50% luminal diameter narrowing of the stent segment or peri-stent segment. EAT volume was compared between patients with and without ISR and additional well-known predictors of ISR were compared. RESULTS: EAT volume was significantly increased in patients with ISR compared with those without ISR (154.5 ± 74.6 mL vs. 131.0 ± 52.2 mL, P < 0.001). The relation between ISR and EAT volume remained significant after adjustment for conventional cardiovascular risk factors and angiographic parameters. CONCLUSIONS: EAT volume was related with ISR and may provide additional information for future ISR.