Mortality Incidence of Patients With Non-Obstructive Coronary Artery Disease Diagnosed by Computed Tomography Angiography

doi:10.1016/j.amjcard.2010.08.034

The American Journal of Cardiology

Volume 107, Issue 1, January 2011, Pages 10-16

https://doi.org/10.1016/j.amjcard.2010.08.034 Get rights and content

It was previously reported that event-free survival rates of symptomatic patients with coronary artery disease (CAD) diagnosed by computed tomographic angiography decreased incrementally from normal coronary arteries to obstructive CAD. The aim of this study was to investigate the clinical outcomes of symptomatic patients with nonobstructive CAD with luminal stenoses of 1% to 49% on the basis of coronary plaque morphology in an outpatient setting. Among 3,499 consecutive symptomatic subjects who underwent computed tomographic angiography, 1,102 subjects with nonobstructive CAD (mean age 59 ± 14 years, 69.9% men) were prospectively followed for a mean of 78 ± 12 months. Coronary plaques were defined as noncalcified, mixed, and calcified per patient. Multivariate Cox proportional-hazards models were developed to predict all-cause mortality. The death rate of patients with nonobstructive CAD was 3.1% (34 deaths). The death rate increased incrementally from calcified plaque (1.4%) to mixed plaque (3.3%) to noncalcified plaque (9.6%), as well as from single- to triple-vessel disease (p <0.001). In subjects with mixed or calcified plaques, the death rate increased with the severity of coronary artery calcium from 1 to 9 to ≥400. The risk-adjusted hazard ratios of all-cause mortality in patients with nonobstructive CAD were 3.2 (95% confidence interval 1.3 to 8.0, p = 0.001) for mixed plaques and 7.4 (95% confidence interval 2.7 to 20.1, p = 0.0001) for noncalcified plaques compared with calcified plaques. The areas under the receiver-operating characteristic curve to predict all-cause mortality were 0.75 for mixed and 0.86 for noncalcified coronary lesions. In conclusion, this study demonstrates that the presence of noncalcified and mixed coronary plaques provided incremental value in predicting all-cause mortality in symptomatic subjects with nonobstructive CAD independent of age, gender, and conventional risk factors.

Section snippets

Methods

Among 3,499 consecutive symptomatic subjects with suspected CAD who underwent CTA, 1,102 with nonobstructive CAD (luminal stenoses of 1% to 49%) were prospectively followed for a mean of 78 ± 12 months. Subjects with irregular heart rates, allergies to contrast media, previous known CAD, liver disease, or impaired renal function were excluded. After receiving a full explanation about the procedure, all eligible patients provided signed written informed consent before they underwent CTA.

Results

The study population consisted of 1,102 subjects; 69% were men, and the mean age was 59 ± 14 years (range 36 to 82). Most of the patients were Caucasian (n = 654 [59.3%]); 6.4% (n = 54) were African American, 10.7% (n = 90) Hispanic, 2.5% (n = 21) Asian, and 3.0% (n = 25) of other races or ethnicities. Of the studied subjects with nonobstructive CAD, 501 (45.5%) had calcified, 486 (44.1%) had mixed, and 115 (10.4%) had noncalcified coronary plaques. There were no significant differences among

Discussion

The present study demonstrated that in subjects with nonobstructive CAD, (1) the presence of noncalcified and mixed coronary plaques was associated with worse long-term clinical outcomes compared to those with calcified plaques, independent of cardiovascular risk factors and the number of diseased coronary arteries; (2) noncalcified and mixed coronary plaques were associated with worse clinical outcomes in women; (3) the severity of CAC in mixed and calcified plaques increased the relative risk

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Asymptomatic coronary artery disease assessed by coronary computed tomography in patients with systemic lupus erythematosus: A systematic review and meta-analysis
2022, European Journal of Internal Medicine
Citation Excerpt :
Given chronic inflammatory diseases greatly increase atherosclerotic progression, measurement of CAC by CV CT is currently recommended in individuals with borderline intermediate risk categories [7]. A large study [63] found that non-calcified and mixed coronary plaque in women, compared with men, is associated with worse clinical outcomes, an extremely pertinent finding for the treatment of young women with SLE. The integration of CCTA as a marker may capture residual CVD risk in patients with SLE, particularly severe initial disease and/or lupus nephritis, which has recently been associated with greater mortality [64,65].
Coronary artery disease (CAD) assessed by coronary computed tomography (CT) in patients with systemic lupus erythematosus (SLE) has been investigated in several studies, but with conflicting results. The aim of this systematic review and meta-analysis of the literature was synthesize the evidence on this topic.
The relevant literature was identified and evaluated from inception until January 2021 in PubMed, Embase, Web of Science and Cochrane library. Studies reporting coronary artery calcification (CAC), and its prevalence and extent using the coronary calcium score (CCS) were included. Data extracted from eligible studies were used to calculate effect estimates (ESs) and 95% confidence intervals (95%CI) and weighted mean differences (WMD) with 95%CI.
Twenty-four studies were eligible for inclusion. For the CAC prevalence, 11 studies were included (918 SLE patients and 3952 controls) and the pooled prevalence for the random effect was 29.8% (95%CI 25.7–32.9%) for SLE patients and 11.8% (95%CI 16.2-20.4%) in controls (RR 2.22, 95%CI 1.42 to 3.48; p= 0.0005) and no significant increase in the WMD for CCS (MD= 0.32, 95%CI −5.55 to 6.20, p= 0.91) compared with controls in seven studies. Greater organ damage and glucocorticoid use has been associated with a higher CCS. According to two studies, the coronary CT angiography calcified and non-calcified plaque burden were increased in SLE patients compared with controls.
In SLE, asymptomatic CAD by CAC is more prevalent and there is more multivessel disease compared with controls without lupus. However, the extent of CAC was not increased in SLE patients.
PROSPERO CRD42021228710.
Chronic inflammatory diseases and coronary heart disease: Insights from cardiovascular CT
2022, Journal of Cardiovascular Computed Tomography
Epidemiological and clinical studies have demonstrated a consistent relationship between increased systemic inflammation and increased risk of cardiovascular events. In chronic inflammatory states, traditional risk factors only partially account for the development of coronary artery disease (CAD) but underestimate total cardiovascular risk likely due to the residual risk of inflammation. Computed coronary tomography angiography (CCTA) may aid in risk stratification by noninvasively capturing early CAD, identifying high risk plaque morphology and quantifying plaque at baseline and in response to treatment. In this review, we focus on reviewing studies on subclinical atherosclerosis by CCTA in individuals with chronic inflammatory conditions including rheumatoid arthritis (RA), systemic lupus erythematous (SLE), human immunodeficiency virus (HIV) infection and psoriasis. We start with a brief review on the role of inflammation in atherosclerosis, highlight the utility of using CCTA to delineate vessel wall and plaque characteristics and discuss combining CCTA with laboratory studies and emerging technologies to complement traditional risk stratification in chronic inflammatory states.
Coronary artery disease burden in women poorly explained by traditional risk factors: Sex disaggregated analyses from the BioHEART-CT study
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Targeting the modifiable risk factors for coronary artery disease (CAD) has substantial impact at the community level. However, it is not uncommon for individuals to present with atherosclerosis related events without identified risk factors. We examined sex differences in the association of risk factors and atherosclerotic burden assessed by CT coronary angiography (CTCA).
We analysed clinical and imaging data in 1002 individuals in the BioHEART cohort.
45% were female, 35% had no CAD identified. Median coronary calcium score was 9.9 Agatston units (IQR: 0–146), and median Gensini Score was 3.5 (IQR: 0–11.5). 26% had a calcified plaque predominant phenotype, and 18% had a non-calcified plaque predominant phenotype. There were no sex differences in the prevalence of risk factors. However, there were notable sex differences in the adjusted associations of risk factors with CAD. Age and hypercholesterolaemia (OR 1.56, 95% CI 1.03–2.36, p = 0.04 in males, and OR 1.75, 95% CI 1.09–2.78, p = 0.02 in females) were associated with the presence of CAD in both genders (p < 0.05). Diabetes and smoking were associated with presence of CAD, calcified CAD, and non-calcified plaque in males (p < 0.05) but not females. In women, none of the standard modifiable risk factors were associated with the amount of plaque present when adjusted for age, BMI, and family history of premature CAD.
CTCA provides an important opportunity for improving the stratification of cohorts to assess underlying biology and risk. We demonstrate sex-specific differences in associations of risk factors with atherosclerosis burden.
Myocardial Infarction Without Obstructive Coronary Artery Disease (MINOCA): A Practical Guide for Clinicians
2021, Current Problems in Cardiology
Myocardial infarction without obstructive coronary artery disease (MINOCA) is defined by the evidence of spontaneous acute myocardial infarction (MI) and angiographic exclusion of coronary stenoses ≥50% in any potential infarct related artery, after having ruled out other clinically overt causes for the acute presentation. The introduction of this new concept was meant to encourage discovery of putative pathophysiological mechanisms and development of specific therapeutic measures. In recent years, we have witnessed significant advances in the fields of epidemiology, pathophysiology, diagnosis, prognosis estimation and therapeutics of MINOCA. So far, however, the definition of MINOCA has been rather heterogeneous since specific cardiac conditions such as myocarditis and Takotsubo syndrome have often been included, generating conflicting results. In this review, we summarize the current state-of-the-art in the expanding MINOCA field and propose a comprehensive stepwise approach for the rational diagnostic assessment of these challenging patients. Our aim is to provide clinicians with an “Ariadne's thread” according to the recent fourth universal definition of MI in order to not get lost in MINOCA's labyrinth.
Society of Cardiovascular Computed Tomography / North American Society of Cardiovascular Imaging – Expert Consensus Document on Coronary CT Imaging of Atherosclerotic Plaque
2021, Journal of Cardiovascular Computed Tomography
Coronary computed tomographic angiography (CCTA) provides a wealth of clinically meaningful information beyond anatomic stenosis alone, including the presence or absence of nonobstructive atherosclerosis and high-risk plaque features as precursors for incident coronary events. There is, however, no uniform agreement on how to identify and quantify these features or their use in evidence-based clinical decision-making. This statement from the Society of Cardiovascular Computed Tomography and North American Society of Cardiovascular Imaging addresses this gap and provides a comprehensive review of the available evidence on imaging of coronary atherosclerosis. In this statement, we provide standardized definitions for high-risk plaque (HRP) features and distill the evidence on the effectiveness of risk stratification into usable practice points. This statement outlines how this information should be communicated to referring physicians and patients by identifying critical elements to include in a structured CCTA report - the presence and severity of atherosclerotic plaque (descriptive statements, CAD-RADS™ categories), the segment involvement score, HRP features (e.g., low attenuation plaque, positive remodeling), and the coronary artery calcium score (when performed). Rigorous documentation of atherosclerosis on CCTA provides a vital opportunity to make recommendations for preventive care and to initiate and guide an effective care strategy for at-risk patients.
Associations of HDL metrics with coronary artery calcium score and density among women traversing menopause
2021, Journal of Lipid Research
The cardioprotective association of high-density lipoprotein cholesterol (HDL-C) may vary by menopause stage or estradiol level. We tested whether associations of comprehensive HDL metrics (HDL subclasses, phospholipid and triglyceride content, and HDL cholesterol efflux capacity [HDL-CEC]) with coronary artery calcium (CAC) score and density vary by menopause stage or estradiol level in women transitioning through menopause. Participants (N = 294; mean age [SD]: 51.3 [2.9]) had data on HDL metrics and CAC measures at one or two time points during the menopause transition. Generalized estimating equations were used for analyses. Effect modifications by menopause stage or estradiol level were tested in multivariable models. In adjusted models, menopause stage modified the associations of specific HDL metrics with CAC measures. Higher small HDL particles (HDL-P) concentrations (p-interaction = 0.008) and smaller HDL size (p-interaction = 0.02) were associated with greater odds of CAC presence in late perimenopause than in pre/early perimenopause stage. Women in the highest estradiol tertile, but not the lower tertiles, showed a protective association of small HDL-P with CAC presence (p-interaction = 0.007). Lower large HDL-P concentrations (p-interaction = 0.03) and smaller HDL size (p-interaction = 0.03) were associated with lower CAC density in late perimenopause than in postmenopause stage. Associations of HDL phospholipid and triglyceride content and HDL-CEC with CAC measures did not vary by menopause stage or estradiol level. We concluded that HDL subclasses may impact the likelihood of CAC presence and the stability of coronary plaque differently over the menopause transition. Endogenous estradiol levels may contribute to this observation.

View all citing articles on Scopus

: Dr. Budoff is a member of the speaker's bureau for General Electric (Milwaukee, Wisconsin).

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Coronary artery diseaseMortality Incidence of Patients With Non-Obstructive Coronary Artery Disease Diagnosed by Computed Tomography Angiography

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Med Clin North Am

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Soc Echocardiogr

J Am Coll Cardiol

Atherosclerosis

Predictive value of 16-slice multidetector spiral computed tomography to detect significant obstructive coronary artery disease in patients at high risk for coronary artery disease: patient-versus segment-based analysis

Circulation

Coronary artery disease
Mortality Incidence of Patients With Non-Obstructive Coronary Artery Disease Diagnosed by Computed Tomography Angiography