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Chang, Hyuk-Jae,Lin, Fay Y.,Gebow, Dan,An, Hae Young,Andreini, Daniele,Bathina, Ravi,Baggiano, Andrea,Beltrama, Virginia,Cerci, Rodrigo,Choi, Eui-Young,Choi, Jung-Hyun,Choi, So-Yeon,Chung, Namsik,Cole American College of Cardiology 2019 JACC. Cardiovascular imaging Vol.12 No.7
<P><B>Graphical abstract</B></P><P>[Figure]</P><P><B>Abstract</B></P><P><B>Objectives</B></P><P>This study compared the safety and diagnostic yield of a selective referral strategy using coronary computed tomographic angiography (CCTA) compared with a direct referral strategy using invasive coronary angiography (ICA) as the index procedure.</P><P><B>Background</B></P><P>Among patients presenting with signs and symptoms suggestive of coronary artery disease (CAD), a sizeable proportion who are referred to ICA do not have a significant, obstructive stenosis.</P><P><B>Methods</B></P><P>In a multinational, randomized clinical trial of patients referred to ICA for nonemergent indications, a selective referral strategy was compared with a direct referral strategy. The primary endpoint was noninferiority with a multiplicative margin of 1.33 of composite major adverse cardiovascular events (blindly adjudicated death, myocardial infarction, unstable angina, stroke, urgent and/or emergent coronary revascularization or cardiac hospitalization) at a median follow-up of 1-year.</P><P><B>Results</B></P><P>At 22 sites, 823 subjects were randomized to a selective referral and 808 to a direct referral strategy. At 1 year, selective referral met the noninferiority margin of 1.33 (p = 0.026) with a similar event rate between the randomized arms of the trial (4.6% vs. 4.6%; hazard ratio: 0.99; 95% confidence interval: 0.66 to 1.47). Following CCTA, only 23% of the selective referral arm went on to ICA, which was a rate lower than that of the direct referral strategy. Coronary revascularization occurred less often in the selective referral group compared with the direct referral to ICA (13% vs. 18%; p < 0.001). Rates of normal ICA were 24.6% in the selective referral arm compared with 61.1% in the direct referral arm of the trial (p < 0.001).</P><P><B>Conclusions</B></P><P>In stable patients with suspected CAD who are eligible for ICA, the comparable 1-year major adverse cardiovascular events rates following a selective referral and direct referral strategy suggests that both diagnostic approaches are similarly effective. In the selective referral strategy, the reduced use of ICA was associated with a greater diagnostic yield, which supported the usefulness of CCTA as an efficient and accurate method to guide decisions of ICA performance. (Coronary Computed Tomographic Angiography for Selective Cardiac Catheterization [CONSERVE]; NCT01810198)</P>
Coronary Atherosclerotic Precursors of Acute Coronary Syndromes
Chang, Hyuk-Jae,Lin, Fay Y.,Lee, Sang-Eun,Andreini, Daniele,Bax, Jeroen,Cademartiri, Filippo,Chinnaiyan, Kavitha,Chow, Benjamin J.W.,Conte, Edoardo,Cury, Ricardo C.,Feuchtner, Gudrun,Hadamitzky, Marti Elsevier 2018 JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY - Vol.71 No.22
<P><B>Abstract</B></P> <P><B>Background</B></P> <P>The association of atherosclerotic features with first acute coronary syndromes (ACS) has not accounted for plaque burden.</P> <P><B>Objectives</B></P> <P>The purpose of this study was to identify atherosclerotic features associated with precursors of ACS.</P> <P><B>Methods</B></P> <P>We performed a nested case-control study within a cohort of 25,251 patients undergoing coronary computed tomographic angiography (CTA) with follow-up over 3.4 ± 2.1 years. Patients with ACS and nonevent patients with no prior coronary artery disease (CAD) were propensity matched 1:1 for risk factors and coronary CTA–evaluated obstructive (≥50%) CAD. Separate core laboratories performed blinded adjudication of ACS and culprit lesions and quantification of baseline coronary CTA for percent diameter stenosis (%DS), percent cross-sectional plaque burden (PB), plaque volumes (PVs) by composition (calcified, fibrous, fibrofatty, and necrotic core), and presence of high-risk plaques (HRPs).</P> <P><B>Results</B></P> <P>We identified 234 ACS and control pairs (age 62 years, 63% male). More than 65% of patients with ACS had nonobstructive CAD at baseline, and 52% had HRP. The %DS, cross-sectional PB, fibrofatty and necrotic core volume, and HRP increased the adjusted hazard ratio (HR) of ACS (1.010 per %DS, 95% confidence interval [CI]: 1.005 to 1.015; 1.008 per percent cross-sectional PB, 95% CI: 1.003 to 1.013; 1.002 per mm<SUP>3</SUP> fibrofatty plaque, 95% CI: 1.000 to 1.003; 1.593 per mm<SUP>3</SUP> necrotic core, 95% CI: 1.219 to 2.082; all p < 0.05). Of the 129 culprit lesion precursors identified by coronary CTA, three-fourths exhibited <50% stenosis and 31.0% exhibited HRP.</P> <P><B>Conclusions</B></P> <P>Although ACS increases with %DS, most precursors of ACS cases and culprit lesions are nonobstructive. Plaque evaluation, including HRP, PB, and plaque composition, identifies high-risk patients above and beyond stenosis severity and aggregate plaque burden.</P> <P><B>Central Illustration</B></P> <P>[DISPLAY OMISSION]</P>
Schulman-Marcus, Joshua,Lin, Fay Y.,Gransar, Heidi,Berman, Daniel,Callister, Tracy,DeLago, Augustin,Hadamitzky, Martin,Hausleiter, Joerg,Al-Mallah, Mouaz,Budoff, Matthew,Kaufmann, Philipp,Achenbach, S Oxford University Press 2017 European heart journal cardiovascular Imaging Vol.18 No.8
<P><B>Abstract</B></P><P><B>Aims</B></P><P>To identify the effect of early revascularization on 5-year survival in patients with CAD diagnosed by coronary-computed tomographic angiography (CCTA).</P><P><B>Methods and results</B></P><P>We examined 5544 stable patients with suspected CAD undergoing CCTA who were followed a median of 5.5 years in a large international registry. Patients were categorized as having low-, intermediate-, or high-risk CAD based on CCTA findings. Two treatment groups were defined: early revascularization within 90 days of CCTA (<I>n</I> = 1171) and medical therapy (<I>n</I> = 4373). To account for the non-randomized referral to revascularization, we developed a propensity score by logistic regression. This score was incorporated into Cox proportional hazard models to calculate the effect of revascularization on all-cause mortality. Death occurred in 363 (6.6%) patients and was more frequent in medical therapy. In multivariable models, when compared with medical therapy, the mortality benefit of revascularization varied significantly over time and by CAD risk (<I>P</I> for interaction 0.04). In high-risk CAD, revascularization was significantly associated with lower mortality at 1 year (hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.11–0.47) and 5 years (HR 0.31, 95% CI 0.18–0.54). For intermediate-risk CAD, revascularization was associated with reduced mortality at 1 year (HR 0.45, 95% CI 0.22–0.93) but not 5 years (HR 0.63, 95% CI 0.33–1.20). For low-risk CAD, there was no survival benefit at either time point.</P><P><B>Conclusions</B></P><P>Early revascularization was associated with reduced 1-year mortality in intermediate- and high-risk CAD detected by CCTA, but this association only persisted for 5-year mortality in high-risk CAD.</P>
Evaluation of Atherosclerotic Plaque in Non-invasive Coronary Imaging
Aeshita Dwivedi,Subhi J. Al’Aref,Fay Y. Lin,James K. Min 대한심장학회 2018 Korean Circulation Journal Vol.48 No.2
Coronary artery disease (CAD) is the leading cause of morbidity and mortality worldwide. Over the last decade coronary computed tomography angiography (CCTA) has gained wide acceptance as a reliable, cost-effective and non-invasive modality for diagnosis and prognostication of CAD. Use of CCTA is now expanding to characterization of plaque morphology and identification of vulnerable plaque. Additionally, CCTA is developing as a non-invasive modality to monitor plaque progression, which holds future potential in individualizing treatment. In this review, we discuss the role of CCTA in diagnosis and management of CAD. Additionally, we discuss the recent advancements and the potential clinical applications of CCTA in management of CAD
Multimodality Imaging in Coronary Artery Disease: Focus on Computed Tomography
이지현,한동희,Ibrahim Danad,Bríain ó Hartaigh,Fay Y. Lin,James K. Min 한국심초음파학회 2016 Journal of Cardiovascular Imaging (J Cardiovasc Im Vol.24 No.1
Coronary artery disease (CAD) is the leading cause of mortality worldwide, and various cardiovascular imaging modalities havebeen introduced for the purpose of diagnosing and determining the severity of CAD. More recently, advances in computed tomography(CT) technology have contributed to the widespread clinical application of cardiac CT for accurate and noninvasive evaluationof CAD. In this review, we focus on imaging assessment of CAD based upon CT, which includes coronary artery calciumscreening, coronary CT angiography, myocardial CT perfusion, and fractional flow reserve CT. Further, we provide a discussion regardingthe potential implications, benefits and limitations, as well as the possible future directions according to each modality.
Han, Donghee,Torii, Sho,Yahagi, Kazuyuki,Lin, Fay Y.,Lee, Ji Hyun,Rizvi, Asim,Gransar, Heidi,Park, Mahn-Won,Roudsari, Hadi Mirhedayati,Stuijfzand, Wijnand J.,Baskaran, Lohendran,ó,Hartaigh, Br&i Elsevier Scientific Publ. Co 2018 Atherosclerosis Vol. No.
<P><B>Abstract</B></P> <P><B>Background and aims</B></P> <P>Recent advancements in coronary computed tomography angiography (CCTA) have allowed for the quantitative measurement of high-risk lipid rich plaque. Determination of the optimal threshold for Hounsfield units (HU) by CCTA for identifying lipid rich plaque remains unknown. We aimed to validate reliable cut-points of HU for quantitative assessment of lipid rich plaque.</P> <P><B>Methods</B></P> <P>8 post-mortem sudden coronary death hearts were evaluated with CCTA and histologic analysis. Quantitative plaque analysis was performed in histopathology images and lipid rich plaque area was defined as intra-plaque necrotic core area. CCTA images were analyzed for quantitative plaque measurement. Low attenuation plaque (LAP) was defined as any pixel < 30, 45, 60, 75, and 90 HU cut-offs within a coronary plaque. The area of LAP was calculated in each cross-section.</P> <P><B>Results</B></P> <P>Among 105 cross-sections<B>,</B> 37 (35.2%) cross-sectional histology images contained lipid rich plaque. Although the highest specificity for identifying lipid rich plaque was shown with <30 HU cut-off (88.2%), sensitivity (e.g. 55.6% for <75 HU, 16.2% for <30 HU) and negative predictive value (e.g. 75.9% for <75 HU, 65.9% for <30 HU) tended to increase with higher HU cut-offs. For quantitative measurement, <75 HU showed the highest correlation coefficient (0.292, <I>p</I> = 0.003) and no significant differences were observed between lipid rich plaque area and LAP area between histology and CT analysis (Histology: 0.34 ± 0.73 mm<SUP>2</SUP>, QCT: 0.37 ± 0.71 mm<SUP>2</SUP>, <I>p</I> = 0.701).</P> <P><B>Conclusions</B></P> <P>LAP area by CCTA using a <75 HU cut-off value demonstrated high sensitivity and quantitative agreement with lipid rich plaque area by histology analysis.</P> <P><B>Highlights</B></P> <P> <UL> <LI> Lipid rich plaques are related to future risk of acute coronary syndrome. </LI> <LI> Quantitative coronary plaque (QCT) analysis enables to quantify lipid rich plaques. </LI> <LI> 75 HU is a reliable cut-off for quantification of lipid rich plaque in QCT analysis. </LI> </UL> </P>
Cho, Iksung,ó,Hartaigh, Brí,ain,Gransar, Heidi,Valenti, Valentina,Lin, Fay Y.,Achenbach, Stephan,Berman, Daniel S.,Budoff, Matthew J.,Callister, Tracy Q.,Al-Mallah, Mouaz H.,Cademartiri, F Elsevier 2017 Atherosclerosis Vol.262 No.-
<P><B>Abstract</B></P> <P><B>Background and aims</B></P> <P>Coronary artery calcium (CAC) scoring is a predictor of future adverse clinical events, and a surrogate measure of overall coronary artery plaque burden. Coronary computed tomographic angiography (CCTA) is a contrast-enhanced method that allows for visualization of plaque as well as whether that plaque causes luminal narrowing. To date, the prognosis of individuals with CAC but without stenosis has not been reported. We explored the prevalence of CAC>0 and its prognostic utility for future mortality for patients without luminal narrowing by CCTA.</P> <P><B>Methods</B></P> <P>From 17 sites in 9 countries, we identified patients without known coronary artery disease, who underwent CAC scoring and CCTA, and were followed for >3 years. CCTA was graded for % stenosis according to a modified American Heart Association 16-segment model. We calculated hazard ratios (HR) with 95% confidence intervals (95% CI) for incident mortality and compared risk of death for patients as a function of presence or absence of CAC and presence or absence of luminal narrowing by CCTA.</P> <P><B>Results</B></P> <P>Among 6656 patients who underwent CCTA and CAC scoring, 399 patients (6.0%) had no coronary luminal narrowing but CAC>0. During a median follow-up of 5.1 years (IQR: 3.9–5.9 years), 456 deaths occurred. Compared to individuals without luminal narrowing or CAC, individuals without luminal narrowing but CAC>0 were older, more likely to be male and had higher rates of diabetes, hypertension, and dyslipidemia. Individuals without luminal narrowing but CAC experienced a 2-fold increased risk of mortality, with increasing risk of mortality with higher CAC score. Following adjustment, incident death persisted (HR, 1.8; 95% CI, 1.1–2.9, <I>p</I> = 0.02) among patients without luminal narrowing but with CAC>0 compared with patients whose CACS = 0. Individuals without luminal narrowing but CAC ≥100 had mortality risks similar to individuals with non-obstructive CAD (0 < stenosis<50%) by CCTA [HR 2.5 (95% CI 1.3–4.9) and 2.2 (95% CI 1.6–3.0), respectively].</P> <P><B>Conclusions</B></P> <P>Patients without luminal narrowing but with CAC experience greater risk of 5-year mortality. Patients with CAC score ≥100 and no coronary luminal narrowing experience death rates similar to those with non-obstructive CAD.</P> <P><B>Highlights</B></P> <P> <UL> <LI> The prevalence of individuals without coronary stenosis but with evident coronary calcium was identified in this large international coronary CT angiography registry. </LI> <LI> Coronary plaques with positive remodeling reflect a potential mechanism for the presence of coronary calcium without luminal narrowing. </LI> <LI> The current study observed a worsened prognosis among those without luminal narrowing but with coronary artery calcium. </LI> </UL> </P>
Cho, Iksung,Chang, Hyuk-Jae,Ó,Hartaigh, Brí,ain,Shin, Sanghoon,Sung, Ji Min,Lin, Fay Y.,Achenbach, Stephan,Heo, Ran,Berman, Daniel S.,Budoff, Matthew J.,Callister, Tracy Q.,Al-Mallah, Moua The European Society of Cardiology 2015 European heart journal Vol.36 No.8
<P><B>Aim</B></P><P>Prior evidence observed no predictive utility of coronary CT angiography (CCTA) over the coronary artery calcium score (CACS) and the Framingham risk score (FRS), among asymptomatic individuals. Whether the prognostic value of CCTA differs for asymptomatic patients, when stratified by CACS severity, remains unknown.</P><P><B>Methods and results</B></P><P>From a 12-centre, 6-country observational registry, 3217 asymptomatic individuals without known coronary artery disease (CAD) underwent CACS and CCTA. Individuals were categorized by CACS as: 0–10, 11–100, 101–400, 401–1000, >1000. For CCTA analysis, the number of obstructive vessels—as defined by the per-patient presence of a ≥50% luminal stenosis—was used to grade the extent and severity of CAD. The incremental prognostic value of CCTA over and above FRS was measured by the likelihood ratio (LR) <I>χ</I><SUP>2</SUP>, <I>C</I>-statistic, and continuous net reclassification improvement (NRI) for prediction, discrimination, and reclassification of all-cause mortality and non-fatal myocardial infarction. During a median follow-up of 24 months (25th–75th percentile, 17–30 months), there were 58 composite end-points. The incremental value of CCTA over FRS was demonstrated in individuals with CACS >100 (LR<I>χ</I><SUP>2</SUP>, 25.34; increment in <I>C</I>-statistic, 0.24; NRI, 0.62, all <I>P</I> < 0.001), but not among those with CACS ≤100 (all <I>P</I> > 0.05). For subgroups with CACS >100, the utility of CCTA for predicting the study end-point was evident among individuals whose CACS ranged from 101 to 400; the observed predictive benefit attenuated with increasing CACS.</P><P><B>Conclusion</B></P><P>Coronary CT angiography provides incremental prognostic utility for prediction of mortality and non-fatal myocardial infarction for asymptomatic individuals with moderately high CACS, but not for lower or higher CACS.</P>