Progression of non-obstructive coronary plaque: a practical CCTA-based risk score from the PARADIGM registry.

OBJECTIVES: No clear recommendations are endorsed by the different scientific societies on the clinical use of repeat coronary computed tomography angiography (CCTA) in patients with non-obstructive coronary artery disease (CAD). This study aimed to develop and validate a practical CCTA risk score to predict medium-term disease progression in patients at a low-to-intermediate probability of CAD. METHODS: Patients were part of the Progression of AtheRosclerotic PlAque Determined by Computed Tomographic Angiography Imaging (PARADIGM) registry. Specifically, 370 (derivation cohort) and 219 (validation cohort) patients with two repeat, clinically indicated CCTA scans, non-obstructive CAD, and absence of high-risk plaque (≥ 2 high-risk features) at baseline CCTA were included. Disease progression was defined as the new occurrence of ≥ 50% stenosis and/or high-risk plaque at follow-up CCTA. RESULTS: In the derivation cohort, 104 (28%) patients experienced disease progression. The median time interval between the two CCTAs was 3.3 years (2.7-4.8). Odds ratios for disease progression derived from multivariable logistic regression were as follows: 4.59 (95% confidence interval: 1.69-12.48) for the number of plaques with spotty calcification, 3.73 (1.46-9.52) for the number of plaques with low attenuation component, 2.71 (1.62-4.50) for 25-49% stenosis severity, 1.47 (1.17-1.84) for the number of bifurcation plaques, and 1.21 (1.02-1.42) for the time between the two CCTAs. The C-statistics of the model were 0.732 (0.676-0.788) and 0.668 (0.583-0.752) in the derivation and validation cohorts, respectively. CONCLUSIONS: The new CCTA-based risk score is a simple and practical tool that can predict mid-term CAD progression in patients with known non-obstructive CAD. CLINICAL RELEVANCE STATEMENT: The clinical implementation of this new CCTA-based risk score can help promote the management of patients with non-obstructive coronary disease in terms of timing of imaging follow-up and therapeutic strategies. KEY POINTS: • No recommendations are available on the use of repeat CCTA in patients with non-obstructive CAD. • This new CCTA score predicts mid-term CAD progression in patients with non-obstructive stenosis at baseline. • This new CCTA score can help guide the clinical management of patients with non-obstructive CAD.

Performance of a Novel CT-Derived Fractional Flow Reserve Measurement to Detect Hemodynamically Significant Coronary Stenosis.

BACKGROUND: Fractional flow reserve (FFR) based on computed tomography (CT) has been shown to better identify ischemia-causing coronary stenosis. However, this current technology requires high computational power, which inhibits its widespread implementation in clinical practice. This prospective, multicenter study aimed at validating the diagnostic performance of a novel simple CT based fractional flow reserve (CT-FFR) calculation method in patients with coronary artery disease. METHODS: Patients who underwent coronary CT angiography (CCTA) within 90 days and invasive coronary angiography (ICA) were prospectively enrolled. A hemodynamically significant lesion was defined as an FFR ≤ 0.80, and the area under the receiver operating characteristic curve (AUC) was the primary measure. After the planned analysis for the initial algorithm A, we performed another set of exploratory analyses for an improved algorithm B. RESULTS: Of 184 patients who agreed to participate in the study, 151 were finally analyzed. Hemodynamically significant lesions were observed in 79 patients (52.3%). The AUC was 0.71 (95% confidence interval [CI], 0.63-0.80) for CCTA, 0.65 (95% CI, 0.56-0.74) for CT-FFR algorithm A (P = 0.866), and 0.78 (95% CI, 0.70-0.86) for algorithm B (P = 0.112). Diagnostic accuracy was 0.63 (0.55-0.71) for CCTA alone, 0.66 (0.58-0.74) for algorithm A, and 0.76 (0.68-0.82) for algorithm B. CONCLUSION: This study suggests the feasibility of automated CT-FFR, which can be performed on-site within several hours. However, the diagnostic performance of the current algorithm does not meet the a priori criteria for superiority. Future research is required to improve the accuracy.

Glycemic control is independently associated with rapid progression of coronary atherosclerosis in the absence of a baseline coronary plaque burden: a retrospective case-control study from the PARADIGM registry.

BACKGROUND: The baseline coronary plaque burden is the most important factor for rapid plaque progression (RPP) in the coronary artery. However, data on the independent predictors of RPP in the absence of a baseline coronary plaque burden are limited. Thus, this study aimed to investigate the predictors for RPP in patients without coronary plaques on baseline coronary computed tomography angiography (CCTA) images. METHODS: A total of 402 patients (mean age: 57.6 ± 10.0 years, 49.3% men) without coronary plaques at baseline who underwent serial coronary CCTA were identified from the Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging (PARADIGM) registry and included in this retrospective study. RPP was defined as an annual change of ≥ 1.0%/year in the percentage atheroma volume (PAV). RESULTS: During a median inter-scan period of 3.6 years (interquartile range: 2.7-5.0 years), newly developed coronary plaques and RPP were observed in 35.6% and 4.2% of the patients, respectively. The baseline traditional risk factors, i.e., advanced age (≥ 60 years), male sex, hypertension, diabetes mellitus, hyperlipidemia, obesity, and current smoking status, were not significantly associated with the risk of RPP. Multivariate linear regression analysis showed that the serum hemoglobin A1c level (per 1% increase) measured at follow-up CCTA was independently associated with the annual change in the PAV (ß: 0.098, 95% confidence interval [CI]: 0.048-0.149; P < 0.001). The multiple logistic regression models showed that the serum hemoglobin A1c level had an independent and positive association with the risk of RPP. The optimal predictive cut-off value of the hemoglobin A1c level for RPP was 7.05% (sensitivity: 80.0%, specificity: 86.7%; area under curve: 0.816 [95% CI: 0.574-0.999]; P = 0.017). CONCLUSION: In this retrospective case-control study, the glycemic control status was strongly associated with the risk of RPP in patients without a baseline coronary plaque burden. This suggests that regular monitoring of the glycemic control status might be helpful for preventing the rapid progression of coronary atherosclerosis irrespective of the baseline risk factors. Further randomized investigations are necessary to confirm the results of our study. TRIAL REGISTRATION: ClinicalTrials.gov NCT02803411.

A deep learning-based automatic analysis of cardiovascular borders on chest radiographs of valvular heart disease: development/external validation.

OBJECTIVES: Cardiovascular border (CB) analysis is the primary method for detecting and quantifying the severity of cardiovascular disease using posterior-anterior chest radiographs (CXRs). This study aimed to develop and validate a deep learning-based automatic CXR CB analysis algorithm (CB_auto) for diagnosing and quantitatively evaluating valvular heart disease (VHD). METHODS: We developed CB_auto using 816 normal and 798 VHD CXRs. For validation, 640 normal and 542 VHD CXRs from three different hospitals and 132 CXRs from a public dataset were assigned. The reliability of the CB parameters determined by CB_auto was evaluated. To evaluate the differences between parameters determined by CB_auto and manual CB drawing (CB_hand), the absolute percentage measurement error (APE) was calculated. Pearson correlation coefficients were calculated between CB_hand and echocardiographic measurements. RESULTS: CB parameters determined by CB_auto yielded excellent reliability (intraclass correlation coefficient > 0.98). The 95% limits of agreement for the cardiothoracic ratio were 0.00 ± 0.04% without systemic bias. The differences between parameters determined by CB_auto and CB_hand as defined by the APE were < 10% for all parameters except for carinal angle and left atrial appendage. In the public dataset, all CB parameters were successfully drawn in 124 of 132 CXRs (93.9%). All CB parameters were significantly greater in VHD than in normal controls (all p < 0.05). All CB parameters showed significant correlations (p < 0.05) with echocardiographic measurements. CONCLUSIONS: The CB_auto system empowered by deep learning algorithm provided highly reliable CB measurements that could be useful not only in daily clinical practice but also for research purposes. KEY POINTS: • A deep learning-based automatic CB analysis algorithm for diagnosing and quantitatively evaluating VHD using posterior-anterior chest radiographs was developed and validated. • Our algorithm (CB_auto) yielded comparable reliability to manual CB drawing (CB_hand) in terms of various CB measurement variables, as confirmed by external validation with datasets from three different hospitals and a public dataset. • All CB parameters were significantly different between VHD and normal control measurements, and echocardiographic measurements were significantly correlated with CB parameters measured from normal control and VHD CXRs.

Association between Aortic Valve Calcification Progression and Coronary Atherosclerotic Plaque Volume Progression in the PARADIGM Registry.

Background Aortic valve calcification (AVC) is a key feature of aortic stenosis, and patients with aortic stenosis often have coronary -artery disease. Therefore, proving the association between the progression of AVC and coronary atherosclerosis could improve follow-up and treatment strategies. Purpose To explore the association between the progression of AVC and the progression of total and plaque volume composition from a large multicenter registry of serial coronary CT angiographic examinations. Materials and Methods A prospective multinational registry (PARADIGM) of consecutive participants who underwent serial coronary CT angiography at intervals of every 2 years or more was performed (January 2003-December 2015). AVC and the total and plaque volume composition at baseline and follow-up angiography were quantitatively analyzed. Plaque volumes were normalized by using the mean total analyzed vessel length of the study population. Multivariable linear mixed-effects models were constructed. Results Overall, 594 participants (mean age ± standard deviation, 62 years ± 10; 330 men) were included (mean interval between baseline and follow-up angiography, 3.9 years ± 1.5). At baseline, the AVC score was 31 Agatston units ± 117, and the normalized total plaque volume at baseline was 122 mm3 ± 219. After adjustment for age, sex, clinical risk factors, and medication use, AVC was independently associated with total plaque volume (standardized ß = 0.24; 95% CI: 0.16, 0.32; P < .001) and both calcified (ß = 0.26; 95% CI: 0.18, 0.34; P < .001) and noncalcified (ß = 0.17; 95% CI: 0.08, 0.25; P < .001) plaque volumes at baseline. The progression of AVC was associated with the progression of total plaque volume (ß = 0.13; 95% CI: 0.03, 0.22; P = .01), driven solely by calcified plaque volume (ß = 0.24; 95% CI: 0.14, 0.34; P < .001) but not noncalcified plaque volumes (ß = -0.06; 95% CI: -0.14, 0.03; P = .17). Conclusion The overall burden of coronary atherosclerosis was associated with aortic valve calcification at baseline. However, the progression of aortic valve calcification was associated with only the progression of calcified plaque volume but not with the -progression of noncalcified plaque volume. Clinical trial registration no. NCT02803411 © RSNA, 2021 See also the editorial by Sinitsyn in this issue.

Concurrent smoking and alcohol consumers had higher triglyceride glucose indices than either only smokers or alcohol consumers: a cross-sectional study in Korea.

BACKGROUND: The triglyceride glucose (TyG) index is a noninsulin-based marker for insulin resistance (IR) in general practice. Although smoking and heavy drinking have been regarded as major risk factors for various chronic diseases, there is limited evidence regarding the combined effects of smoking and alcohol consumption on IR. This study aimed to investigate the relationship between the TyG index and smoking and alcohol consumption using two Korean population-based datasets. METHODS: This study included 10,568 adults in the Korean National Health and Nutrition Examination Survey (KNHANES) and 9586 adults in the Korean Initiatives on Coronary Artery Calcification (KOICA) registry datasets. Multivariate logistic analysis was conducted to explore the relationship between smoking and alcohol consumption and the TyG index. To assess the predictive value of smoking and alcohol consumption on high TyG index, the area under the curve (AUC) were compared and net reclassification improvement (NRI) and integrated discrimination improvement (IDI) analyses were derived. RESULTS: The combined effect of smoking and alcohol consumption was an independent risk factor of a higher TyG index in the KNHANES (adjusted odds ratio: 4.33, P < .001) and KOICA (adjusted odds ratio: 1.94, P < .001) datasets. Adding smoking and alcohol consumption to the multivariate logistic models improved the model performance for the TyG index in the KNHANES (AUC: from 0.817 to 0.829, P < .001; NRI: 0.040, P < .001; IDI: 0.017, P < .001) and KOICA (AUC: from 0.822 to 0.826, P < .001; NRI: 0.025, P = .006; IDI: 0.005, P < .001) datasets. CONCLUSIONS: Smoking and alcohol consumption were independently associated with the TyG index. Concurrent smokers and alcohol consumers were more likely to have a TyG index that was ≥8.8 and higher than the TyG indices of non-users and those who exclusively consumed alcohol or smoking tobacco.

High prevalence of a linear valve-like structure on CT at the pulmonary artery terminus of patent ductus arteriosus in adult patients, mimicking endarteritis.

PURPOSE: A linear valve-like structure at the pulmonary artery terminus is identified on CT in some patients with patent ductus arteriosus (PDA) and can potentially be mistaken for endarteritis. The purpose of this study was to evaluate the differences in CT features between adult patients with PDA and a linear structure and those without. MATERIALS AND METHODS: We retrospectively evaluated ECG-gated cardiac CT of 38 patients with PDA dividing them into two groups [patients with linear symmetrical valve-like structure (group1, n = 16), and those without (group 2, n = 22)]. We analyzed CT findings of the PDA including length, minimal and maximal diameter, presence of calcification, and PDA type, comparing the two subgroups. The authors also investigated the prevalence of endarteritis. RESULTS: There was no difference in CT findings between the two groups in the prevalence of calcification and length, and minimal and maximal diameter of PDA. Notably the linear valve-like structure was only identified in type 1 PDA (cone-shaped PDA) (p = 0.04), while there were variable types of PDA in group 2. There was only one case of endarteritis as a complication of PDA in group 1. In contrast to a linear valve-like structure, asymmetrical nodular thickening was noted in the patient with endarteritis on CT overlying the pre-existing linear valve-like structure at the pulmonary end of PDA. CONCLUSION: A linear valve-like structure is frequently identified at the pulmonary end in type 1 PDA. This CT finding should not be mistaken for endarteritis in the absence of other clinical evidence.

Triglyceride glucose index is an independent predictor for the progression of coronary artery calcification in the absence of heavy coronary artery calcification at baseline.

BACKGROUND: Data on the relationship between the triglyceride glucose (TyG) index and coronary artery calcification (CAC) progression is limited. This longitudinal study evaluated the association of TyG index with CAC progression in asymptomatic adults. METHODS: We enrolled 12,326 asymptomatic Korean adults who had at least two CAC evaluations. The TyG index was determined using ln (fasting triglycerides [mg/dL] × fasting glucose [mg/dL]/2). CAC progression was defined as a difference ≥ 2.5 between the square roots (√) of the baseline and follow-up coronary artery calcium score (CACS) (Δ√transformed CACS). Annualized Δ√transformed CACS was defined as Δ√transformed CACS divided by the inter-scan period. RESULTS: During a mean 3.3 years, the overall incidence of CAC progression was 30.6%. The incidence of CAC progression (group I [lowest]: 22.7% versus [vs.] group II: 31.7% vs. group III [highest]: 37.5%, P < 0.001) and annualized Δ√transformed CACS (group I: 0.46 ± 1.44 vs. group II: 0.71 ± 2.02 vs. group III: 0.87 ± 1.75, P < 0.001) were markedly elevated with increasing TyG index tertiles. Multivariate linear regression analysis showed that TyG index was associated with annualized Δ√transformed CACS (ß = 0.066, P = 0.036). In multivariate logistic regression analysis, the TyG index was significantly associated with CAC progression in baseline CACS ≤ 100. CONCLUSION: The TyG index is an independent predictor of CAC progression, especially in adults without heavy baseline CAC.

Quantitative assessment of coronary plaque volume change related to triglyceride glucose index: The Progression of AtheRosclerotic PlAque DetermIned by Computed TomoGraphic Angiography IMaging (PARADIGM) registry.

BACKGROUND: The association between triglyceride glucose (TyG) index and coronary atherosclerotic change remains unclear. We aimed to evaluate the association between TyG index and coronary plaque progression (PP) using serial coronary computed tomography angiography (CCTA). METHODS: A total of 1143 subjects (aged 60.7 ± 9.3 years, 54.6% male) who underwent serial CCTA with available data on TyG index and diabetic status were analyzed from The Progression of AtheRosclerotic PlAque DetermIned by Computed TomoGraphic Angiography IMaging (PARADIGM) registry. PP was defined as plaque volume (PV) (mm3) at follow-up minus PV at index > 0. Annual change of PV (mm3/year) was defined as PV change divided by inter-scan period. Rapid PP was defined as the progression of percent atheroma volume (PV divided by vessel volume multiplied by 100) ≥ 1.0%/year. RESULTS: The median inter-scan period was 3.2 (range 2.6-4.4) years. All participants were stratified into three groups based on TyG index tertiles. The overall incidence of PP was 77.3%. Baseline total PV (group I [lowest]: 30.8 (0.0-117.7), group II: 47.2 (6.2-160.4), and group III [highest]: 57.5 (8.4-154.3); P < 0.001) and the annual change of total PV (group I: 5.7 (0.0-20.2), group II: 7.6 (0.5-23.5), and group III: 9.4 (1.4-27.7); P = 0.010) were different among all groups. The risk of PP (odds ratio [OR] 1.648; 95% confidence interval [CI] 1.167-2.327; P = 0.005) and rapid PP (OR 1.777; 95% CI 1.288-2.451; P < 0.001) was increased in group III compared to that in group I. TyG index had a positive and significant association with an increased risk of PP and rapid PP after adjusting for confounding factors. CONCLUSION: TyG index is an independent predictive marker for the progression of coronary atherosclerosis. Clinical registration ClinicalTrials.gov NCT02803411.

Effect of cilostazol on carotid plaque volume measured by three-dimensional ultrasonography in patients with type 2 diabetes: The FANCY study.

AIMS: To conduct a prospective randomized study to evaluate cilostazol, a phosphodiesterase 3 inhibitor, and compare it with aspirin for the prevention of the progression of atherosclerosis in patients with type 2 diabetes (T2D). MATERIALS AND METHODS: Fifty patients with T2D and carotid atherosclerotic plaques were randomly assigned to either a 200 mg/d cilostazol (CTZ) group or a 100 mg/d aspirin (ASA) group for 6 months. The primary endpoint was change in plaque volume measured by carotid three-dimensional ultrasonography. The secondary endpoints were changes in carotid intima-media thickness (IMT) and endothelial function, assessed by laser Doppler. RESULTS: Twenty-four patients in the CTZ group and 23 in the ASA group were included in the final analysis. The mean ± SD age of male (n = 20) and female (n = 16) patients was 62.2 and 59.1 years, respectively. The total plaque volume was slightly decreased in the CTZ group (from 183.8 ± 52.5 to 181.5 ± 54.0 mm3 ; P = .567), but significantly increased in the ASA group (from 112.9 ± 21.2 to 128.5 ± 23.3 mm3 ; P = .043). A significant regression in the maximum IMT was observed only in the CTZ group (right: from 2.19 ± 0.17 to 1.96 ± 0.12 mm; left: from 2.02 ± 0.20 to 1.72 ± 0.19 mm). The CTZ group exhibited an increase in HDL cholesterol and a decrease in triglycerides and liver enzymes. CONCLUSIONS: Cilostazol treatment for 6 months significantly attenuated the progression of carotid plaque compared with aspirin in patients with T2D (NCT03248401).

A Patient-Specific 3Dt Coronary Artery Motion Modeling Method Using Hierarchical Deformation with Electrocardiogram.

Cardiovascular-related diseases are one of the leading causes of death worldwide. An understanding of heart movement based on images plays a vital role in assisting postoperative procedures and processes. In particular, if shape information can be provided in real-time using electrocardiogram (ECG) signal information, the corresponding heart movement information can be used for cardiovascular analysis and imaging guides during surgery. In this paper, we propose a 3D+t cardiac coronary artery model which is rendered in real-time, according to the ECG signal, where hierarchical cage-based deformation modeling is used to generate the mesh deformation used during the procedure. We match the blood vessel's lumen obtained from the ECG-gated 3D+t CT angiography taken at multiple cardiac phases, in order to derive the optimal deformation. Splines for 3D deformation control points are used to continuously represent the obtained deformation in the multi-view, according to the ECG signal. To verify the proposed method, we compare the manually segmented lumen and the results of the proposed method for eight patients. The average distance and dice coefficient between the two models were 0.543 mm and 0.735, respectively. The required time for registration of the 3D coronary artery model was 23.53 s/model. The rendering speed to derive the model, after generating the 3D+t model, was faster than 120 FPS.

Clinical significance of evaluating coronary atherosclerosis in adult patients with hypertrophic cardiomyopathy who have chest pain.

OBJECTIVE: Chest pain is a common symptom in patients with hypertrophic cardiomyopathy (HCM), causing difficulty determining whether there is coexistent coronary artery disease (CAD). We investigated whether coronary computed tomography angiography (CCTA) can assess the prevalence and clinical significance of CAD in adult patients with HCM showing chest pain through longitudinal follow-up. METHODS: In 238 adult patients with HCM, who underwent CCTA for chest pain, we analyzed the degree of stenosis and adverse plaque characteristics (APCs) as CCTA variables. Three prediction models for adverse cardiovascular events (ACEs: all-cause mortality, myocardial infarction, unstable angina, heart failure, implantable cardioverter-defibrillator implantation, and stroke) were assessed using the combination of clinical risk factors, echocardiographic parameters, and CCTA variables. RESULTS: The prevalence of obstructive CAD (≥ 50% in luminal stenosis) and APC was 14.7% and 18.9%, respectively. During the follow-up period (median, 37 months; range, 2-108 months), there were 31 occurrences of ACEs (13.0%). Using multivariate Cox regression analysis, age, atrial fibrillation, low ejection fraction, obstructive CAD, and APCs were associated with ACEs (all p < 0.05). Among the prediction models for ACEs, the area under the curve (AUC) was higher (AUC = 0.92) when CCTA variables were added to the clinical (AUC = 0.84) and echocardiographic factors (AUC = 0.88) (p < 0.001). CONCLUSIONS: Using CCTA, about 20% of symptomatic HCM patients were associated with clinically significant atherosclerosis. Adding these CCTA variables to the clinical and echocardiographic variables may increase the predictions of ACEs; therefore, evaluating coronary atherosclerosis using CCTA may be helpful for symptomatic HCM patients. KEY POINTS: • Chest pain in adult patients with hypertrophic cardiomyopathy (HCM) remains challenging to distinguish from coronary artery disease. • Coronary computed tomography angiography (CCTA) can assess the severity and characteristics of coronary atherosclerosis in symptomatic HCM patients. • Adding CCTA variables to clinical and echocardiographic factors may increase the predictions of adverse cardiac events in HCM patients, and thus evaluating coronary atherosclerosis using CCTA may be helpful for HCM patients with chest pain.

Effect of cilostazol, a phosphodiesterase-3 inhibitor, on coronary artery stenosis and plaque characteristics in patients with type 2 diabetes: ESCAPE study.

AIM: To perform a prospective study to evaluate the effect of cilostazol (CTZ) compared with aspirin (acetylsalicylic acid; ASA) in Korean people with diabetes and subclinical coronary atherosclerosis. MATERIALS AND METHODS: A total of 100 people with diabetes who had mild to moderate coronary atherosclerosis, assessed by coronary computed tomographic angiography (CCTA), were randomly assigned to either 200 mg/d CTZ or 100 mg/d ASA (n = 50 each group). The primary outcome was change in coronary artery stenosis assessed by CCTA after 12 months of treatment. Secondary outcomes included changes in plaque composition, coronary artery calcium score and cardiac markers. RESULTS: The mean age, body mass index and glycated haemoglobin concentration were 61.5 years, 25.0 kg/m2 and 56.8 mmol/mol, respectively, and were well matched between the two groups. Coronary artery stenosis decreased in the CTZ group (from 44.0 ± 2.1% to 40.4 ± 2.5%) but remained unchanged in the ASA group (from 38.9 ± 2.1% to 40.6 ± 2.1%). In the CTZ group, the non-calcified portion of plaques decreased significantly (from 20.6 ± 3.0 to 17.3 ± 3.0 mm3 ), whereas it did not change significantly in the ASA group (15.2 ± 2.8 vs 16.6 ± 2.9 mm3 ). Increases in HDL cholesterol, decreases in triglycerides, liver enzyme and high-sensitivity C-reactive protein levels, and reductions in abdominal visceral fat area and insulin resistance were observed only in the CTZ group. CONCLUSION: CTZ treatment for 12 months decreased coronary artery stenosis and the non-calcified plaque component. These results suggest that CTZ treatment may be an option for preventing the progression of coronary atherosclerosis in people with diabetes.

Relevance of anatomical, plaque, and hemodynamic characteristics of non-obstructive coronary lesions in the prediction of risk for acute coronary syndrome.

OBJECTIVES: We explored the anatomical, plaque, and hemodynamic characteristics of high-risk non-obstructive coronary lesions that caused acute coronary syndrome (ACS). METHODS: From the EMERALD study which included ACS patients with available coronary CT angiography (CCTA) before the ACS, non-obstructive lesions (percent diameter stenosis < 50%) were selected. CCTA images were analyzed for lesion characteristics by independent CCTA and computational fluid dynamics core laboratories. The relative importance of each characteristic was assessed by information gain. RESULTS: Of the 132 lesions, 24 were the culprit for ACS. The culprit lesions showed a larger change in FFRCT across the lesion (ΔFFRCT) than non-culprit lesions (0.08 ± 0.07 vs 0.05 ± 0.05, p = 0.012). ΔFFRCT showed the highest information gain (0.051, 95% confidence interval [CI] 0.050-0.052), followed by low-attenuation plaque (0.028, 95% CI 0.027-0.029) and plaque volume (0.023, 95% CI 0.022-0.024). Lesions with higher ΔFFRCT or low-attenuation plaque showed an increased risk of ACS (hazard ratio [HR] 3.25, 95% CI 1.31-8.04, p = 0.010 for ΔFFRCT; HR 2.60, 95% CI 1.36-4.95, p = 0.004 for low-attenuation plaque). The prediction model including ΔFFRCT, low-attenuation plaque and plaque volume showed the highest ability in ACS prediction (AUC 0.725, 95% CI 0.724-0.727). CONCLUSION: Non-obstructive lesions with higher ΔFFRCT or low-attenuation plaque showed a higher risk of ACS. The integration of anatomical, plaque, and hemodynamic characteristics can improve the noninvasive prediction of ACS risk in non-obstructive lesions. KEY POINTS: • Change in FFR CT across the lesion (ΔFFR CT ) was the most important predictor of ACS risk in non-obstructive lesions. • Non-obstructive lesions with higher ΔFFR CT or low-attenuation plaque were associated with a higher risk of ACS. • The integration of anatomical, plaque, and hemodynamic characteristics can improve the noninvasive prediction of ACS risk.

Incidence and predictors of venous thromboembolism in medically ill hospitalized elderly cancer patients: a prospective observational study.

PURPOSE: The aim of this study was to estimate the incidence and predictors of venous thromboembolism (VTE) in medically ill hospitalized elderly cancer patients in a single Korean tertiary hospital. METHODS: Patients were examined for deep vein thrombosis (DVT) by duplex and color Doppler ultrasonography (DUS) of both legs between days 5 and 14 of their hospital stays. The primary endpoint was the incidence of VTE by day 14, which was determined via a composite of DVT detected by routine DUS and symptomatic VTE. RESULTS: A total of 140 patients with 31 hematologic and 109 nonhematologic malignancies were analyzed. The median age was 73 years, and 45.7% of the patients were female. The median length of hospital stay was 12 days. The modified Padua prediction score (PPS) ≥ 4 was 92.9%. The incidence of VTE by day 14 was 7.1%, including six proximal and four distal DVT cases. Being female, having a length of hospital stay of ≥ 13 days, and having a modified Padua prediction score of ≥ 6 were risk factors of VTE in univariate analysis. The incidence of VTE was 2.3%, 7.3%, and 41.7% in patients with 0-1, 2, and 3 of these risk factors, respectively. CONCLUSION: The incidence of VTE in medically ill hospitalized elderly cancer patients was lower in Korean patients than in Western patients. However, the risk of VTE in those with more than two risk factors (female, long length of hospitalization, and high PPS) increased considerably, and pharmacologic thromboprophylaxis is warranted in these cases.

Evaluation of the impact of glycemic status on the progression of coronary artery calcification in asymptomatic individuals.

BACKGROUND: Data on the influence of glycemic status on the progression of coronary calcification, an important marker for future adverse cardiovascular events, are limited. METHODS: Data from the Korea Initiatives on Coronary Artery Calcification (KOICA) registry on 12,441 asymptomatic Korean adults (52 ± 9 years, 84.2% males) without previous history of coronary artery disease and stroke, who underwent serial coronary artery calcification (CAC) screening examinations, were included in this study. The median inter-scan period was 3.0 (2.0-4.8) years. All participants were categorized into three groups based on their glycemic status: normal (n = 6578), pre-diabetes (n = 4146), and diabetes (n = 1717). CAC progression was defined as a difference ≥ 2.5 between the square roots (√) of the baseline and follow-up CAC scores. RESULTS: The incidence of CAC progression was significantly different between the three groups (normal, 26.3%; pre-diabetes, 30.9%; and diabetes, 46.9%; p < 0.001). In the univariate logistic analysis, the risk of CAC progression was higher in the pre-diabetes (odds ratio [OR] 1.253; 95% confidential interval [CI] 1.150-1.366) and diabetes (OR 2.471; 95% CI 2.215-2.758) groups than in the normal group (p < 0.001, both). In the multivariate logistic analysis, the risk of CAC progression was not significantly different between the normal and pre-diabetes groups but was significantly higher in the diabetes group than in the normal group. CONCLUSIONS: In asymptomatic subjects, diabetes had an incremental impact on CAC progression; however, pre-diabetes did not increase the risk of CAC progression after adjusting for confounding factors.

Prediction of infarct size and adverse cardiac outcomes by tissue tracking-cardiac magnetic resonance imaging in ST-segment elevation myocardial infarction.

OBJECTIVES: We investigated whether quantification of global left ventricular (LV) strain by tissue tracking-CMR (TT-CMR) can estimate the infarct size and clinical outcomes in patients with acute myocardial infarction (MI). METHODS: We retrospectively registered 247 consecutive patients (58 ± 12 years; male, 81%) who underwent 1.5-T CMR within 1 month after ST-segment elevation MI (median, 4 days; interquartile range, 3-6 days), and 20 age- and sex-matched controls (58 ± 11 years; male, 80%). TT-CMR analysis was applied to cine-images to measure global LV radial, circumferential and longitudinal peak strains (GRS, GCS and GLS, respectively). Adverse cardiac events were defined as cardiac death and hospitalization for heart failure. RESULTS: During the follow-up (median, 7.8 years), 20 patients (8.1%) experienced adverse events. LV myocardial deformation was significantly decreased in MI patients compared to controls and closely related to the infarct size. The GRS, GCS and GLS were all significant predictors of adverse cardiac events. In particular, a GLS > -14.1% was independently associated with a > 5-fold increased risk for adverse events, even after adjustment for the LV ejection fraction and infarct size. CONCLUSIONS: TT-CMR-derived LV strain is significantly related to the infarct size and adverse events. GLS measurement provides strong prognostic information in MI patients. KEY POINTS: • TT-CMR provides reliable quantification of LV strain in MI patients. • TT-CMR allows prediction of the infarct size and adverse events. • In particular, GLS by TT-CMR had independent prognostic value in MI patients.

Discrepancies between coronary CT angiography and invasive coronary angiography with focus on culprit lesions which cause future cardiac events.

OBJECTIVES: To evaluate the clinical significance of discrepant lesions between coronary computed tomography angiography (CCTA) and invasive coronary angiography (ICA) in a longitudinal study. METHODS: In 220 patients with suspected coronary artery disease (CAD) who underwent both 256-row CCTA and ICA, the obstructive CAD (≥ 50% stenosis) on CCTA was compared with that on ICA as the reference standard. We analysed the causes of the discrepancy between CCTA and ICA. During a 40-month follow-up period, major adverse cardiac events (MACE) were assessed. RESULTS: Discordance between CCTA and ICA was observed in 121 of the 3166 coronary artery segments (3.8%). Common causes were calcification (45.9%) and positive remodelling (PR) (29.6%) in 83 false positive lesions, and noise (40.0%) and motion artefact (37.8%) in 38 false negative lesions. MACE occurred in seven lesions among the discrepant lesions; six among the 29 PR lesions (20.7%) and one among the 53 calcified lesions (1.9%). With respect to the prediction power of MACE in an intermediate stenosis, the CCTA-related value including PR was higher than the ICA-related value. CONCLUSIONS: PR was a frequent cause of MACE among the false positive lesions on CCTA. Therefore, the presence of PR on CCTA may suggest clinical significance, although it can be missed by ICA. KEY POINTS: • Compared to ICA, PR in CCTA may be cause of false positive lesion. • CCTA-related value including PR shows higher prediction power of MACE than ICA-related value. • PR reflects atherosclerotic burden that can be related to cardiac events. • PR in CCTA should be observed carefully, even if it is false positive.

Coronary Artery Fistulas: Pathophysiology, Imaging Findings, and Management.

Coronary artery fistulas (CAFs) are abnormal communications of coronary arteries whereby venous circuits bypass the normal capillaries within the myocardium. CAFs are rare, and most affected patients are asymptomatic. However, these fistulas are the most common coronary artery anomalies that can alter coronary hemodynamic parameters. Although most CAFs are asymptomatic in young patients, symptoms and complications become more frequent with increasing age. CAFs are characterized by variable clinical manifestations that are based on the size, origin, and drainage site of the fistula. In symptomatic cases, surgical ligation or percutaneous transcatheter closure is often recommended. Although CAFs historically have been evaluated with conventional invasive angiography, electrocardiographically gated cardiac computed tomographic (CT) angiography has emerged as the noninvasive alternative modality of choice owing to the high spatial and temporal resolution and short acquisition time. Furthermore, three-dimensional volume-rendered CT angiograms facilitate accurate assessment of the complex anatomy of CAFs, including their origin, drainage site, and complexity and the number and size of fistulous tracts. Knowledge of these characteristics is crucial for therapeutic planning. Radiologists must be aware of the pathophysiology, clinical manifestations, and characteristic CT angiographic findings of CAFs; appropriate CT angiographic protocols for evaluation of various CAFs; and the role of CT angiography in preprocedural planning and follow-up. Online supplemental material is available for this article. ©RSNA, 2018.

Imaging of Myocardial Ischemia-Reperfusion Injury Using Sodium [18F]Fluoride Positron Emission Tomography/Computed Tomography in Rats and Humans.

Positron emission tomography (PET)/computed tomography (CT) using sodium [18F]fluoride (Na[18F]F) has been proven to be a promising hot-spot imaging modality for myocardial infarction (MI). We investigated Na[18F]F uptake in ischemia-reperfusion injury (IRI) of rats and humans. Sodium [18F]fluoride PET/CT was performed in Sprague-Dawley rats that had IRI surgery, and it readily demonstrated prominent Na[18F]F uptake in the infarct area post-IRI. Sodium [18F]fluoride uptake was matched with negative 2,3,5-triphenyl-2 H-tetrazolium chloride staining results, accompanied by myocardial apoptosis and associated with positive calcium staining results. Furthermore, area at risk was negative for Na[18F]F uptake. Cyclosporine A (CysA) treatment reduced standardized uptake value of 18F over the infarct area, and a significant decrease in infarct size was also observed by the CysA treatment. In humans, Na[18F]F PET/CT readily demonstrated increased Na[18F]F uptake in the 2 patients with MI post-percutaneous coronary intervention. In conclusion, this study sheds light on the potential utility of Na[18F]F PET/CT as a hot-spot imaging modality for myocardial IRI.