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The aim of this study was to determine the predictive value of 64-slice computed tomography coronary angiography (CTCA) for major cardiac events in patients with suspected coronary artery disease (CAD). A total of 187 consecutive patients (119 men, age 62.5 +/- 10.5 years) without known heart disease underwent single-source 64-slice CTCA (Somatom S...
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... observers who were unaware of the clinical history of the patients. In case of disagreement, a joint reading was performed and a consensus reached. Coronary arteries were divided into 15 segments according to the modified American Heart Association classification [7] and, where present, the intermediate branch was added to the classi- fication ( Fig. 1). All coronary segments were considered in the analysis. First, each segment was classified as assessable or not assessable. All assessable segments were then evaluated for the presence of any atherosclerotic plaque. Axial images and curved multiplanar reconstruc- tions of the segmental vasculature were utilized for the assessment. ...
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Citations
... Severe coronary atherosclerosis is often silent in diabetic patients [1]. Consequently, it has been proposed to screen diabetic patients for infraclinic coronary atherosclerosis by calcium scoring in order to conduct functional testing only in the specific subgroup of high risk patients with severe infraclinic calcified coronary atherosclerosis [2][3][4][5][6][7][8]. Thus, Coronary Artery Calcium Score (CAC) measurement by Multiple Detector Computed Tomography (MDCT) is nowadays recommended to measure the intensity and the diffusion of silent coronary calcified plaques, to reclassify cardiovascular risk by several scientific societies [9,10]. ...
Aim
Noninvasive assessment of infraclinic coronary atherosclerosis by coronary artery calcium score (CAC) measurement leads to the identification of incidental findings. The aim of this study was to determine the prevalence of incidental findings following systematic CAC assessment in diabetic patients with high cardiovascular risk, to identify the determinants, and to assess the midterm consequences of these findings in patient care.
Methods
732 consecutive asymptomatic patients (187 type 1 diabetes (TD1), 482 type 2 diabetes (TD2) and 63 type 3 diabetes (TD3)) aged 60.6±0.7 years who had a CAC assessment by Multiple Detector Computed Tomography between 2015 and 2017 were systematically included. Clinical and biological data were collected from medical electronic files.
Results
117/732 diabetic patients (16.0%) had incidental findings of which 105 (14.3%) were unknown. Incidental findings were more frequent in TD3 (23.8%) and TD2 (17.0%) than in TD1 (10.7%) (p = 0.05). 76 diabetic patients (10.4%) had lung abnormalities, mainly pulmonary nodules (31 patients, 4.2%). The other incidental finding were pericardial (1.5%), vascular (1.2%), thymic (0.7%) and digestive diseases (0.5%). 42.6% of patients with incidental findings had an additional TDM and 56.8% a specialized medical advice. In 10 patients (9.3% of incidental findings), the identification of incidental finding led to a specific treatment of the underlying disease. In multivariate analysis, microalbuminuria, type of diabetes (TD2/TD3 vs TD1) and smoking were significantly associated with incidental findings (p = 0.003; p = 0.026; p = 0.050 respectively).
Conclusions
Incidental findings are not rare in diabetic patients upon CAC assessment. A fraction of them are accessible to specific treatment. These findings raise the question if a systematic low dose chest TDM should be conducted in TD2 or TD3 patients and in any diabetic smokers by enlarging the window used for CAC assessment.
... Multi slice CT angiography is more sensitive and specific than MR angiography in the detection of significant (>50% diameter) stenosis of the coronary arteries. In addition to coronary artery calcium scoring, CT angiography allows direct evaluation of the coronary arteries and the severity of stenosis and may offer advantage over conventional angiography to quantify and characterize atherosclerotic plaques, provide independent prognostic information for predicting cardiac events and mortality in patients with known or suspected [8][9] CAD . ...
... In particular, in the setting of ischemic heart disease, CTCA has shown high sensitivity and very high negative predictive value (≥95%) for significant CAD (8,9). CTCA also carries an important prognostic value, being the only technique able to measure atheroma burden along the entire length of the coronary arteries (10)(11)(12)(13)(14) and assess its composition (15). The large multi-center SCOT-HEART (16) and PROMISE (17) trials have supported a role for CTCA in diagnosis of significant CAD in stable patients, due to a significantly lower rates of mortality from CAD and nonfatal myocardial infarction in the CTCA arm as compared to standard care (16) or functional testing (17). ...
Cardiac computed tomography (CCT) has rapidly evolved, becoming a powerful integrated tool for the evaluation of coronary artery disease (CAD), and being superior to other noninvasive methods due to its high accuracy and ability to simultaneously assess both lumen stenosis and atherosclerotic plaque burden. Furthermore, CCT is regarded as an effective gatekeeper for coronary angiography, and carries independent important prognostic information. In the last decade, the introduction of new functional CCT applications, namely CCT perfusion (CCTP) imaging and CT-derived fractional flow reserve (FFRCTA), has opened the door for accurate assessment of the haemodynamic significance of stenoses. These new CCT technologies, thus, share the unique advantage of assessing both myocardial ischemia and patient-specific coronary artery anatomy, providing an integrated anatomical/functional analysis. In the present review, starting from the pathophysiology of myocardial ischemia, we evaluate the existing evidence for functional CCT imaging and its value in relation to alternative, well-established, non-invasive imaging modalities and invasive indices of ischemia (currently the gold-standard). The knowledge of clinical applications, benefits, and limitations of these new CCT technologies will allow efficient and optimal use in clinical practice in the near future.
... Coronary CTA has also a prognostic value providing information on the total plaque burden, with a better outcome when there is no evidence of CAD and a worse prognosis in case of detection of coronary atherosclerosis, depending on its severity and extension [10][11][12][13][14][15]. ...
The past two decades have witnessed rapid and remarkable technical improvement of multidetector computed tomography (CT) in both image quality and diagnostic accuracy. These improvements include higher temporal resolution, high-definition and wider detectors, the introduction of dual-source and dual-energy scanners, and advanced postprocessing. Current new generation multidetector row (≥64 slices) CT systems allow an accurate and reliable assessment of both coronary epicardial stenosis and myocardial CT perfusion (CTP) imaging at rest and during pharmacologic stress in the same examination. This novel application makes CT the unique noninvasive “one-stop-shop” method for a comprehensive assessment of both anatomical coronary atherosclerosis and its physiological consequences. Myocardial CTP imaging can be performed with different approaches such as static arterial first-pass imaging, and dynamic CTP imaging, with their own advantages and disadvantages. Static CTP can be performed using single-energy or dual-energy CT, employing qualitative or semiquantitative analysis. In addition, dynamic CTP can obtain quantitative data of myocardial blood flow and coronary flow reserve. The purpose of this review was to summarize all available evidence about the emerging role of myocardial CTP to identify ischemia-associated lesions, focusing on technical considerations, clinical applications, strengths, limitations, and the more promising future fields of interest in the broad spectra of ischemic heart disease.
... A plenty of studies demonstrated the high diagnostic accuracy of CCT ( Table 2) in the diagnostic workup of patients with suspected CAD (3)(4)(5)8,11,(79)(80)(81)(82)(83) and low to intermediate risk of CAD (6,84). CCT was also validated by several outcome studies that investigated risk stratification and prognostic value in registry data (85)(86)(87). Nonetheless, CCT may also provide functional information including regional heart function Tanabe et al. demonstrated that Dynamic CT perfusion has the potential to detect abnormal perfused myocardium and severe infarction assessed by SPECT/CMR using comparable cut-off myocardial blood flow (MBF). ...
... Nonetheless, CCT may also provide functional information including regional heart function Tanabe et al. demonstrated that Dynamic CT perfusion has the potential to detect abnormal perfused myocardium and severe infarction assessed by SPECT/CMR using comparable cut-off myocardial blood flow (MBF). Authors retrospectively evaluated fifty-three patients who underwent stress dynamic CTP and either SPECT (n = 25) or CMR (n = 28) and found that for detecting the abnormal perfused myocardium, sensitivity and specificity were 80% (95% CI, 71-90) and 86% (95% CI, [76][77][78][79][80][81][82][83][84][85][86][87][88][89][90][91] in SPECT (cut-off MBF, 1.23), and 82% (95% CI, [76][77][78][79][80][81][82][83][84][85][86][87][88] and 87% (95% CI, [80][81][82][83][84][85][86][87][88][89][90][91][92] in CMR (cut-off MBF, 1.25) (69). ...
... Nonetheless, CCT may also provide functional information including regional heart function Tanabe et al. demonstrated that Dynamic CT perfusion has the potential to detect abnormal perfused myocardium and severe infarction assessed by SPECT/CMR using comparable cut-off myocardial blood flow (MBF). Authors retrospectively evaluated fifty-three patients who underwent stress dynamic CTP and either SPECT (n = 25) or CMR (n = 28) and found that for detecting the abnormal perfused myocardium, sensitivity and specificity were 80% (95% CI, 71-90) and 86% (95% CI, [76][77][78][79][80][81][82][83][84][85][86][87][88][89][90][91] in SPECT (cut-off MBF, 1.23), and 82% (95% CI, [76][77][78][79][80][81][82][83][84][85][86][87][88] and 87% (95% CI, [80][81][82][83][84][85][86][87][88][89][90][91][92] in CMR (cut-off MBF, 1.25) (69). ...
Myocardial infarction (MI) is a major cause of death and disability worldwide. The incidence is not expected to diminish, despite better prevention, diagnosis and treatment, because of the ageing population in industrialized countries and unhealthy lifestyles in developing countries. Nowadays it is highly requested an imaging tool able to evaluate MI and viability. Technology improvements determined an expansion of clinical indications from coronary plaque evaluation to functional applications (perfusion, ischemia and viability after MI) integrating additional phases and information in the mainstream examination. Cardiac computed tomography (CCT) and cardiac MR (CMR) employ different contrast media, but may characterize MI with overlapping imaging findings due to the similar kinetics and tissue distribution of gadolinium and iodinated contrast media. CCT may detect first-pass perfusion defects, dynamic perfusion after pharmacological stress, and delayed enhancement (DE) of non-viable territories.
... Several studies evaluated the ability of atherosclerotic plaque composition assessment by CCTA to estimate cardiac outcomes in patients with suspected or known CAD and clinically stable chest pain syndrome (Pundziute et al., 2007;Gaemperli et al., 2008;Aldrovandi et al., 2009;Carrigan et al., 2009;Gopal et al., 2009;Hadamitzky et al., 2009;Rubinshtein et al., 2009;van Werkhoven et al., 2009a, reviewed in Bamberg et al., 2011 and summarized in Table 5). The recently published meta-analysis, which systematically reviewed the findings of these studies, included 7335 patients with stable CAD (Bamberg et al., 2011). ...
Despite advances in the pharmacologic and interventional treatment of coronary artery disease (CAD), atherosclerosis remains the leading cause of death in Western societies. X-ray coronary angiography has been the modality of choice for diagnosing the presence and extent of CAD. However, this technique is invasive and provides limited information on the composition of atherosclerotic plaque. Coronary computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR) have emerged as promising non-invasive techniques for the clinical imaging of CAD. Hereby, CCTA allows for visualization of coronary calcification, lumen narrowing and atherosclerotic plaque composition. In this regard, data from the CONFIRM Registry recently demonstrated that both atherosclerotic plaque burden and lumen narrowing exhibit incremental value for the prediction of future cardiac events. However, due to technical limitations with CCTA, resulting in false positive or negative results in the presence of severe calcification or motion artifacts, this technique cannot entirely replace invasive angiography at the present time. CMR on the other hand, provides accurate assessment of the myocardial function due to its high spatial and temporal resolution and intrinsic blood-to-tissue contrast. Hereby, regional wall motion and perfusion abnormalities, during dobutamine or vasodilator stress, precede the development of ST-segment depression and anginal symptoms enabling the detection of functionally significant CAD. While CT generally offers better spatial resolution, the versatility of CMR can provide information on myocardial function, perfusion, and viability, all without ionizing radiation for the patients. Technical developments with these 2 non-invasive imaging tools and their current implementation in the clinical imaging of CAD will be presented and discussed herein.
... In 2006-2007, the researchers dealing with CCT started looking at the next phase (the one after diagnostic accuracy) while implementing the advances that make CCT a low-radiation-dose technique today; this phase was the prognostic phase [7][8][9] . ...
... Various other studies have also evaluated the prognostic value of coronary CTA for identifying a combination of cardiovascular death, MI, and revascularizations across different clinical scenarios. [27][28][29][30][31][32] This has the advantage of focusing on outcomes that are associated with the actual disease process detected by coronary CTA. However, findings from these studies may be driven by revascularizations triggered by the coronary CTA findings. ...
-The contribution of plaque extent to predict cardiovascular (CV) events among patients with non-obstructive and obstructive coronary artery disease (CAD) is not well defined. Our objective was to evaluate the prognostic value of plaque extent detected by coronary computed tomography (CTA).
-All consecutive patients without prior CAD referred for coronary CTA to evaluate for CAD were included. Exam findings were classified as normal, non-obstructive (<50% stenosis) or obstructive (≥50%). Based on the number of segments with disease, extent of CAD was classified as non-extensive (≤4 segments) or extensive (>4 segments). The cohort included 3242 patients followed for the primary outcome of cardiovascular (CV) death or myocardial infarction (MI) for a median of 3.6 (2.1 - 5.0) years. In a multivariable analysis, the presence of extensive non-obstructive CAD (HR 3.1, 95% confidence interval (CI):1.5-6.4); non-extensive obstructive (HR 3.0, 95%CI: 1.3-6.9) and extensive obstructive CAD (HR:3.9, 95%CI:2.2-7.2) were associated with an increased rate of events, while non-extensive non-obstructive CAD was not. The addition of plaque extent to a model that included clinical probability as well as the presence and severity of CAD improved risk prediction.
-Among patients with non-obstructive CAD, those with extensive plaque experienced a higher rate CV death or MI, comparable to those who have non-extensive obstructive disease. Even among patients with obstructive CAD, greater extent of non-obstructive plaque was associated with higher event rate. Our findings suggest that regardless whether obstructive or non-obstructive disease is present, the extent of plaque detected by coronary CTA enhances risk assessment.
... They are long-term retrospective observational cohorts, where CT results have been employed to guide management. [10][11][12][13][14] Although there have been some studies on the importance of CCTA, no study has evaluated this issue in a one-year follow-up of patients for MACE. ...
... In their study 368 patients, with a mean Some other studies showed that in diff erent patients the absence of CAD by CT, predicted that MACE would be absent in a follow-up period of ≤60 months. [13,14,16] In another study, the evaluation of patients presenting to the Emergency Department with acute chest pain was done with CCTA. In this observational study of 368 patients, with a mean age of 53 years, 31 patients (8%) patients had ACS. ...
Coronary computed tomography angiography (CCTA) is a well-known method for evaluating anatomic coronary stenosis, but the reliability of CCTA to predict cardiovascular events is an issue of controversy.
In this prospective observational study, 58 patients with acute chest pain and low-to-moderate risk were selected and CCTA was performed on them. During follow up, the occurrence of major adverse cardiac events (MACE), defined as, cardiac death, myocardial infarction or coronary revascularization, were evaluated. Sensitivity, specificity, and positive and negative predictive values of CCTA for the occurrence of MACE, at the six-month follow up, were also evaluated.
A total of nine (15.5 %) were positive in terms of the MACE criteria and they all had positive CCTA results. It seemed that there was 100% sensitivity for CCTA in predicting the occurrence of MACE. Forty-nine patients had no MACE, among whom 48 patients had negative CCTA. The specificity of CCTA in predicting the occurrence of MACE was 98%. All patients with positive CCTA showed significant stenosis in angiography.
It appears that CCTA allows us to predict the prognosis of patients with acute chest pain and low-to moderate-risk in terms of MACE occurrence.
... Multiple observational studies and three small meta-analyses have suggested that the detection of CAD by CCTA provides predictive information; however, none of these studies has demonstrated an association between cardiac death or MI at each level of CAD severity [6][7][8]. Many studies included coronary revascularization, a rather soft end-point, in the calculation of MACE [9][10][11][12][13]. Several older studies included data obtained by scanners that lack 64-slice or greater technology [6][7][8]. ...
The value of ≥64-slice coronary CT angiography (CCTA) to determine odds of cardiac death or non-fatal myocardial infarction (MI) needs further clarification.
We performed a systematic review and meta-analysis using publications reporting events/severity of coronary artery disease (CAD) in patients with suspected CAD undergoing CCTA. Patients were divided into: no CAD, non-obstructive CAD (maximal stenosis <50%), and obstructive CAD (≥50% stenosis). Odds ratios with 95% confidence intervals were calculated using a fixed or random effects model. Heterogeneity was assessed using the I(2) index.
We included thirty-two studies comprising 41,960 patients with 363 all-cause deaths (15.0%), 114 cardiac deaths (4.7%), 342 MI (14.2%), 69 unstable angina (2.8%), and 1527 late revascularizations (63.2%) over 1.96 (SD 0.77) years of follow-up. Cardiac death or MI occurred in 0.04% without, 1.29% with non-obstructive, and 6.53% with obstructive CAD. OR for cardiac death or MI was: 14.92 (95% CI, 6.78 to 32.85) for obstructive CAD, 6.41 (95% CI, 2.44 to 16.84) for non-obstructive CAD versus no CAD, and 3.19 (95% CI, 2.29 to 4.45) for non-obstructive versus obstructive CAD and 6.56 (95% CI, 3.07 to 14.02) for no versus any CAD. Similar trends were noted for all-cause mortality and composite major adverse cardiovascular events.
Increasing CAD severity detected by CCTA is associated with cardiac death or MI, all-cause mortality, and composite major adverse cardiovascular events. Absence of CAD is associated with very low odds of major adverse events, but non-obstructive disease significantly increases odds of cardiac adverse events in this follow-up period.
