Role of computed tomography for diagnosis and risk stratification of patients with suspected or known coronary artery disease.

Cardiac computed tomographic angiography (CCTA) has emerged as a powerful imaging modality for the detection and prognostication of individuals with suspected coronary artery disease. Because calcification of coronary plaque occurs in proportion to the total atheroma volume, the initial diagnostic potential of CCTA focused on the identification and quantification of coronary calcium in low- to intermediate-risk individuals, a finding that tracks precisely with the risk of incident adverse clinical events. Beyond noncontrast detection of coronary calcium, CCTA using iodinated contrast yields incremental information about the degree and distribution of coronary plaques and stenosis, as well as vessel wall morphology and atherosclerotic plaque features. This additive information offers the promise of CCTA to provide a more comprehensive view of total atherosclerotic burden because it relates to myocardial ischemia and future adverse clinical events. Furthermore, emerging data suggest the prognostic and diagnostic importance of stenosis severity detection and atherosclerotic plaque features described by CCTA including positive remodeling, low-attenuation plaque, and spotty calcification, which have been associated with the vulnerability of plaque. We report a summary of the evidence supporting the role of CCTA in the detection of subclinical and clinical coronary artery disease in both asymptomatic and symptomatic patients and discuss the potential of CCTA to augment the identification of at-risk individuals. CCTA and coronary artery calcium scoring offer the ability to improve risk stratification, discrimination, and reclassification of the risk in patients with suspected coronary artery disease and to noninvasively determine the measures of stenosis severity and atherosclerotic plaque features.

Long-term prognosis for individuals with hypertension undergoing coronary artery calcium scoring.

BACKGROUND: To examine the performance of coronary artery calcification (CAC) for stratifying long-term risk of death in asymptomatic hypertensive patients. METHODS AND RESULTS: 8905 consecutive asymptomatic individuals without cardiovascular disease or diabetes who underwent CAC testing (mean age 53.3 ± 10.5, 59.3% male) were followed for a mean of 14 years and categorized on the background of hypertension as well as age above or below 60 years (in accordance with the 2014 Guidelines from the Joint National Committee 8). The prevalence and severity of CAC were higher for those with hypertension versus without hypertension (P<0.001), and the extent increased proportionally with advancing age (P<0.001). Following adjustment, the presence of CAC in hypertensive with respect to normotensive, was associated with worse prognosis for individuals above the age of 60 years (HR 7.74 [95% CI: 5.15-11.63] vs. HR 4.83 [95% CI: 3.18-7.33]) than individuals below the age of 60 (HR 3.18 [95% CI: 2.42-4.19] vs. HR 2.14 [95% CI: 1.61-2.85]), respectively. A zero CAC score in hypertensive over the age of 60 years was associated with a lower but persisting risk of mortality for (HR 2.48 [95% CI: 1.50-4.08]) that was attenuated non-significant for those below the age of 60 years (P=0.09). In a "low risk" hypertensive population, the presence any CAC was associated with an almost five-fold (HR 4.68 [95% CI: 2.22-9.87]) increased risk of death. CONCLUSION: The presence and extent of CAC effectively may help the clinicians to further discriminate the long-term risk of mortality among asymptomatic hypertensive individuals, beyond conventional cardiovascular risk and current guidelines.