Objectives This study was designed to determine whether multislice computed tomography (MSCT) coronary angiography has incremental prognostic value over single-photon emission computed tomography ...myocardial perfusion imaging (MPI) in patients with suspected coronary artery disease (CAD). Background Although MSCT is used for the detection of CAD in addition to MPI, its incremental prognostic value is unclear. Methods In 541 patients (59% male, age 59 ± 11 years) referred for further cardiac evaluation, both MSCT and MPI were performed. The following events were recorded: all-cause death, nonfatal infarction, and unstable angina requiring revascularization. Results In the 517 (96%) patients with an interpretable MSCT, significant CAD (MSCT ≥50% stenosis) was detected in 158 (31%) patients, and abnormal perfusion (summed stress score SSS: ≥4) was observed in 168 (33%) patients. During follow-up (median 672 days; 25th, 75th percentile: 420, 896), an event occurred in 23 (5.2%) patients. After correction for baseline characteristics in a multivariate model, MSCT emerged as an independent predictor of events with an incremental prognostic value to MPI. The annualized hard event rate (all-cause mortality and nonfatal infarction) in patients with none or mild CAD (MSCT <50% stenosis) was 1.8% versus 4.8% in patients with significant CAD (MSCT ≥50% stenosis). A normal MPI (SSS <4) and abnormal MPI (SSS ≥4) were associated with an annualized hard event rate of 1.1% and 3.8%, respectively. Both MSCT and MPI were synergistic, and combined use resulted in significantly improved prediction (log-rank test p value <0.005). Conclusions MSCT is an independent predictor of events and provides incremental prognostic value to MPI. Combined anatomical and functional assessment may allow improved risk stratification.
Objectives This study sought to determine the diagnostic accuracy of 64-slice computed tomographic coronary angiography (CTCA) to detect or rule out significant coronary artery disease (CAD). ...Background CTCA is emerging as a noninvasive technique to detect coronary atherosclerosis. Methods We conducted a prospective, multicenter, multivendor study involving 360 symptomatic patients with acute and stable anginal syndromes who were between 50 and 70 years of age and were referred for diagnostic conventional coronary angiography (CCA) from September 2004 through June 2006. All patients underwent a nonenhanced calcium scan and a CTCA, which was compared with CCA. No patients or segments were excluded because of impaired image quality attributable to either coronary motion or calcifications. Patient-, vessel-, and segment-based sensitivities and specificities were calculated to detect or rule out significant CAD, defined as ≥50% lumen diameter reduction. Results The prevalence among patients of having at least 1 significant stenosis was 68%. In a patient-based analysis, the sensitivity for detecting patients with significant CAD was 99% (95% confidence interval CI: 98% to 100%), specificity was 64% (95% CI: 55% to 73%), positive predictive value was 86% (95% CI: 82% to 90%), and negative predictive value was 97% (95% CI: 94% to 100%). In a segment-based analysis, the sensitivity was 88% (95% CI: 85% to 91%), specificity was 90% (95% CI: 89% to 92%), positive predictive value was 47% (95% CI: 44% to 51%), and negative predictive value was 99% (95% CI: 98% to 99%). Conclusions Among patients in whom a decision had already been made to obtain CCA, 64-slice CTCA was reliable for ruling out significant CAD in patients with stable and unstable anginal syndromes. A positive 64-slice CTCA scan often overestimates the severity of atherosclerotic obstructions and requires further testing to guide patient management.
Adipose tissue surrounding the coronary arteries has been suggested to induce development of atherosclerosis. We explored the relation between epicardial adipose tissue (EAT) volume and coronary ...atherosclerosis using multislice computed tomography. The study population consisted of 190 patients who had undergone multislice computed tomographic coronary angiography. Coronary artery calcium score was assessed. In addition, patients were classified as having (1) no atherosclerosis, (2) nonobstructive atherosclerosis (luminal narrowing <50%), (3) obstructive atherosclerosis (luminal narrowing ≥50%) in a single vessel, or (4) obstructive atherosclerosis in the left main coronary artery and/or multiple vessels. Cross-sectional tomographic cardiac slices (3.00-mm thickness, range 35 to 40 slices per heart) were traced semiautomatically from the border of EAT below the apex to a point at the center of the left atrium. Tissue with values from −250 to −30 HU was assigned as EAT. EAT volume within the traced area was then automatically quantified. Mean EAT volume was 84 ± 41 ml. Patients with a coronary artery calcium score >10 had significantly larger average EAT volume (100 ± 40 ml) compared with patients with calcium scores ≤10 (59 ± 27 ml, p <0.001). Sensitivity and specificity for prediction of a calcium score >10 were 77% and 70% with a cut-off EAT value of 73 ml. In patients with normal coronaries mean EAT volume (63 ± 31 ml) was significantly smaller than in patients with atherosclerosis (99 ± 40 ml, p <0.001). Using a cut-off EAT volume of 75 ml, the sensitivity and specificity for presence of atherosclerosis were 72% and 70%. Interestingly, quantity of EAT did not significantly increase with increasing extent or severity of atherosclerosis. After adjustments for risk factors EAT volume remained a significant predictor of coronary atherosclerosis (p = 0.001). In conclusion, a significant relation was shown between EAT volume and presence of coronary atherosclerosis. Quantification of EAT may be useful to identify patients at risk for coronary artery disease.
Noninvasive Evaluation With Multislice Computed Tomography in Suspected Acute Coronary Syndrome: Plaque Morphology on Multislice Computed Tomography Versus Coronary Calcium Score Maureen M. Henneman, ...Joanne D. Schuijf, Gabija Pundziute, Jacob M. van Werkhoven, J. Wouter Jukema, Jeroen J. Bax In 40 consecutive patients with suspected acute coronary syndrome (ACS), atherosclerotic plaque burden and morphology were evaluated by multislice computed tomography (MSCT) coronary angiography and related to the calcium score. In 38 patients, coronary artery disease was observed. Coronary calcium was detected in 27 patients, of whom 10 had a score >400. In 13 patients, coronary calcium was absent, but 11 of them had atherosclerosis on MSCT. In patients with suspected ACS, the absence of coronary calcium does not reliably exclude the presence of (significant) atherosclerosis. This information may be of value to improve our understanding of the potential role of MSCT in this patient population.
Background Left ventricular (LV) diastolic dysfunction and subclinical systolic dysfunction may be markers of coronary artery disease (CAD). However, whether these markers are useful for prediction ...of obstructive CAD is unknown. Methods A total of 182 consecutive outpatients (54 ± 10 years, 59% males) without known CAD and overt LV systolic dysfunction underwent 64-slice multislice computed tomography (MSCT) coronary angiography and echocardiography. The MSCT angiograms showing atherosclerosis were classified as showing obstructive (≥50% luminal narrowing) CAD or not. Conventional echocardiographic parameters of LV systolic and diastolic function were obtained; in addition, (1) global longitudinal strain (GLS) and strain rate (indices of systolic function) and (2) global strain rate during the isovolumic relaxation period and during early diastolic filling (indices of diastolic function) were assessed using speckle-tracking echocardiography. In addition, the pretest likelihood of obstructive CAD was assessed using the Duke Clinical Score. Results Based on MSCT, 32% of patients were classified as having no CAD, whereas 33% showed nonobstructive CAD and the remaining 35% had obstructive CAD. Multivariate analysis of clinical and echocardiographic characteristics showed that only high pretest likelihood of CAD (odds ratio OR 3.21, 95% 1.02-10.09, P = .046), diastolic dysfunction (OR 3.72, 95% CI 1.44-9.57, P = .006), and GLS (OR 1.97, 95% CI 1.43-2.71, P < .001) were associated with obstructive CAD. A value of GLS ≥−17.4 yielded high sensitivity and specificity in identifying patients with obstructive CAD (83% and 77%, respectively), providing a significant incremental value over pretest likelihood of CAD and diastolic dysfunction. Conclusions The GLS impairment aids detection of patients without overt LV systolic dysfunction having obstructive CAD.
The impact of left ventricular (LV) dyssynchrony after acute myocardial infarction (AMI) on LV ejection fraction (EF) is unknown. One hundred twenty-nine patients with a first ST-elevation AMI (58 ± ...11 years, 78% men) and QRS duration <120 ms were included. All patients underwent primary percutaneous coronary intervention. Real-time 3-dimensional echocardiography and myocardial contrast echocardiography were performed to assess LV function, LV dyssynchrony, and infarct size. LV dyssynchrony was defined as the SD of the time to reach the minimum systolic volume for 16 LV segments, expressed in percent cardiac cycle (systolic dyssynchrony index SDI). Myocardial perfusion at myocardial contrast echocardiography was scored (1 = normal/homogenous; 2 = decreased/patchy; 3 = minimal/absent) using a 16-segment model; a myocardial perfusion index, expressing infarct size, was derived by summing segmental contrast scores and dividing by the number of segments. SDI in patients with AMI was 5.24 ± 2.23% compared to 2.02 ± 0.70% of controls (p <0.001). Patients with AMI and LVEF <45% had significantly higher SDI compared to patients with LVEF ≥45% (4.29 ± 1.44 vs 6.95 ± 2.40, p <0.001). At multivariate analysis, SDI was independently related to LVEF; in addition, the impact of SDI on LV systolic function was incremental to infarct size and anterior location of AMI (F change 16.9, p <0.001). In conclusion, LV synchronicity is significantly impaired soon after AMI. LV dyssynchrony is related to LVEF and has an additional detrimental effect on LV function, beyond infarct size and the anterior location of AMI.
Data evaluating gender- and age-specific differences in plaque observations on multislice computed tomography (MSCT) are scarce. Accordingly, the aim of this study was to evaluate coronary plaque ...patterns in men and women in relation to age using MSCT. The findings were compared to observations on grayscale intravascular ultrasound (IVUS) and virtual histology (VH) IVUS. In total, 93 patients (59 men, 34 women) underwent 64-slice MSCT followed by conventional coronary angiography with IVUS. Plaque extent and composition were assessed on MSCT, grayscale IVUS, and VH IVUS. Coronary plaque patterns were compared between men and women in 2 age groups (<65 and ≥65 years old). In patients aged <65 years, more plaques were observed on MSCT in men (6 ± 4 vs 2 ± 2 in women, p <0.001). Also, a larger plaque burden was observed on grayscale IVUS in men (45.7 ± 11.4% vs 36.3 ± 11.6% in women, p <0.001). Similarly, more mixed plaques were observed in men (3 ± 3 vs 1 ± 1 in women, p = 0.003), whereas a larger arc of calcium was detected on grayscale IVUS in men (91.7 ± 93.5° vs 25.7 ± 51.0° in women, p <0.001). On VH IVUS, the prevalence of thin-cap fibroatheroma was higher in men (31% vs 0%) compared to women. In patients aged ≥65 years old, no important differences in plaque patterns were observed between men and women. In conclusion, more extensive atherosclerosis and more calcified lesions were observed in men than in women. These differences were predominantly present in patients aged <65 years and were lost in those aged ≥65 years.
The purpose of the present study was to assess the impact of clinical presentation and pretest likelihood on the relation between coronary calcium score (CCS) and computed tomographic coronary ...angiography (CTA) to determine the role of CCS as a gatekeeper to CTA in patients presenting with chest pain. In 576 patients with suspected coronary artery disease (CAD), CCS and CTA were performed. CCS was categorized as 0, 1 to 400, and >400. On CT angiogram the presence of significant CAD (≥50% luminal narrowing) was determined. Significant CAD was observed in 14 of 242 patients (5.8%) with CCS 0, in 94 of 260 patients (36.2%) with CCS 1 to 400, and in 60 of 74 patients (81.1%) with CCS >400. In patients with CCS 0, prevalence of significant CAD increased from 3.9% to 4.1% and 14.3% in nonanginal, atypical, and typical chest pain, respectively, and from 3.4% to 3.9% and 27.3% with a low, intermediate, and high pretest likelihood, respectively. In patients with CCS 1 to 400, prevalence of significant CAD increased from 27.4% to 34.7% and 51.7% in nonanginal, atypical, and typical chest pain, respectively, and from 15.4% to 35.6% and 50% in low, intermediate, and high pretest likelihood, respectively. In patients with CCS >400, prevalence of significant CAD on CT angiogram remained high (>72%) regardless of clinical presentation and pretest likelihood. In conclusion, the relation between CCS and CTA is influenced by clinical presentation and pretest likelihood. These factors should be taken into account when using CCS as a gatekeeper for CTA.
Both myocardial perfusion imaging (MPI) and multislice computed tomography (MSCT) are currently used to detect coronary artery disease (CAD). However, MSCT permits early detection of atherosclerosis ...while myocardial perfusion is still normal. In addition, MPI results can be normal despite the presence of high-risk CAD (left main and balanced 3-vessel CAD). In this study, the range of anatomic findings using MSCT in patients with normal MPI results was evaluated. In 180 patients presenting with chest pain, MPI (with gated single-photon emission computed tomography) and 64-slice MSCT were performed. In patients with normal MPI results, prevalences of completely normal coronary arteries, nonobstructive CAD, and obstructive CAD were determined using MSCT. The occurrence of high-risk CAD, including left main and 3-vessel disease, was also evaluated. Normal MPI and adequate MSCT findings were obtained in 97 patients (54%; 50% women; average age 58 ± 12 years; 5% with known CAD). A total of 38 patients (39%) showed normal coronary anatomy, whereas nonsignificant and significant CAD were observed in 37 (38%) and 18 patients (19%), respectively. Importantly, only 4 patients (4%) presented with high-risk CAD using 64-slice MSCT, 2 with left main and 2 with 3-vessel disease. In conclusion, a normal MPI result can be associated with a wide range of anatomic observations and cannot exclude the presence of both nonobstructive and obstructive CAD. However, importantly, the prevalence of high-risk CAD was rare.
Chronic kidney disease (CKD) is associated with cardiovascular (CV) events caused by advanced atherosclerosis. Computed tomographic coronary angiography (CTA) can accurately diagnose coronary artery ...disease (CAD) and predict CV outcomes. The aim of the present study was to evaluate whether moderate CKD provides prognostic information for CV events in patients undergoing CTA. In total 885 patients with suspected CAD underwent CTA and were stratified to moderate CKD (85 patients) or no CKD (770 patients) based on a cut-off estimated glomerular filtration rate of 60 ml/min/1.73 m2 . After 896 days of follow-up, 42 patients developed CV events. Annualized CV event rates were 1.2% in patients with no CKD and no CAD, 2.5% in patients with moderate CKD alone, 2.5% in patients with obstructive CAD alone, and 3.7% in those with moderate CKD and obstructive CAD. Multivariate models demonstrated that moderate CKD (hazard ratio 2.39, confidence interval 1.09 to 5.21, p = 0.03) and obstructive CAD (hazard ratio 2.76, confidence interval 1.40 to 5.44, p <0.01) were independent predictors of CV events. Importantly, moderate CKD provided incremental prognostic information in addition to clinical characteristics and obstructive CAD (chi-square 49.4, p = 0.04). In conclusion, moderate CKD was associated with CV events and provided incremental prognostic information.
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