CCTA-Derived Adverse Geometric Characteristics Inform Risk Stratification of Patients With Stable CAD
abstract
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Access this abstract nowImportance
Distinct plaque locations and vessel geometric features predispose to altered coronary flow hemodynamics. The association between these lesion-level characteristics assessed by coronary computed tomographic angiography (CCTA) and risk of future acute coronary syndrome (ACS) is unknown.
Objective
To examine whether CCTA-derived adverse geometric characteristics (AGCs) of coronary lesions describing location and vessel geometry add to plaque morphology and burden for identifying culprit lesion precursors associated with future ACS.
Design, Setting, and Participants
This substudy of ICONIC (Incident Coronary Syndromes Identified by Computed Tomography), a multicenter nested case-control cohort study, included patients with ACS and a culprit lesion precursor identified on baseline CCTA (n = 116) and propensity score-matched non-ACS controls (n = 116). Data were collected from July 20, 2012, to April 30, 2017, and analyzed from October 1, 2020, to October 31, 2021.
Exposures
Coronary lesions were evaluated for the following 3 AGCs: (1) distance from the coronary ostium to lesion; (2) location at vessel bifurcations; and (3) vessel tortuosity, defined as the presence of 1 bend of greater than 90° or 3 curves of 45° to 90° using a 3-point angle within the lesion.
Main Outcomes and Measures
Association between lesion-level AGCs and risk of future ACS-causing culprit lesions.
Results
Of 548 lesions, 116 culprit lesion precursors were identified in 116 patients (80 [69.0%] men; mean [SD], age 62.7 [11.5] years). Compared with nonculprit lesions, culprit lesion precursors had a shorter distance from the ostium (median, 35.1 [IQR, 23.6-48.4] mm vs 44.5 [IQR, 28.2-70.8] mm), more frequently localized to bifurcations (85 [73.3%] vs 168 [38.9%]), and had more tortuous vessel segments (5 [4.3%] vs 6 [1.4%]; all P < .05). In multivariable Cox regression analysis, an increasing number of AGCs was associated with a greater risk of future culprit lesions (hazard ratio [HR] for 1 AGC, 2.90 [95% CI, 1.38-6.08]; P = .005; HR for ≥2 AGCs, 6.84 [95% CI, 3.33-14.04]; P < .001). Adverse geometric characteristics provided incremental discriminatory value for culprit lesion precursors when added to a model containing stenosis severity, adverse morphological plaque characteristics, and quantitative plaque characteristics (area under the curve, 0.766 [95% CI, 0.718-0.814] vs 0.733 [95% CI, 0.685-0.782]). In per-patient comparison, patients with ACS had a higher frequency of lesions with adverse plaque characteristics, AGCs, or both compared with control patients (≥2 adverse plaque characteristics, 70 [60.3%] vs 50 [43.1%]; ≥2 AGCs, 92 [79.3%] vs 60 [51.7%]; ≥2 of both, 37 [31.9%] vs 20 [17.2%]; all P < .05).
Conclusions and Relevance
These findings support the concept that CCTA-derived AGCs capturing lesion location and vessel geometry are associated with risk of future ACS-causing culprit lesions. Adverse geometric characteristics may provide additive prognostic information beyond plaque assessment in CCTA.
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Additional Info
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Association of Plaque Location and Vessel Geometry Determined by Coronary Computed Tomographic Angiography With Future Acute Coronary Syndrome-Causing Culprit Lesions
JAMA Cardiol 2022 Jan 26;[EPub Ahead of Print], D Han, A Lin, K Kuronuma, E Tzolos, AC Kwan, E Klein, D Andreini, JJ Bax, F Cademartiri, K Chinnaiyan, BJW Chow, E Conte, RC Cury, G Feuchtner, M Hadamitzky, YJ Kim, JA Leipsic, E Maffei, H Marques, F Plank, G Pontone, TC Villines, MH Al-Mallah, P de Araújo Gonçalves, I Danad, H Gransar, Y Lu, JH Lee, SE Lee, L Baskaran, SJ Al'Aref, YE Yoon, A Van Rosendael, MJ Budoff, H Samady, PH Stone, R Virmani, S Achenbach, J Narula, HJ Chang, JK Min, FY Lin, LJ Shaw, PJ Slomka, D Dey, DS BermanFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
From the large multicenter CONFIRM registry of >25,000 coronary CTA patients, the authors report on a subset who were followed after the initial CCTA study and subsequently had an acute coronary syndrome (ACS), which they refer to as the nested ICONIC registry. Prior studies from this dataset focused on plaque features and reported that, although the risk of subsequent ACS increased as the percentage diameter stenosis increased in the antecedent CCTA (which could have taken place several years before the clinical ACS), most precursors of ACS cases were nonobstructive and adverse plaque characteristics incrementally increased the risk beyond stenosis severity. Those data were part of a robust CCTA literature on multiple adverse plaque characteristics associated with risk of subsequent ACS.
In this paper, the authors use the same ICONIC dataset to examine adverse “geometric” characteristics (AGCs) of lesions within vessels, including distance from ostium, location at bifurcation, and extremes of vessel angulation proximal to the lesion (tortuosity), all of which could plausibly be related to shear stress. They found that all three of those AGCs were associated with subsequent development of a culprit lesion as a cause of an ACS, there was a “dose response” (ie, the more AGCs, the higher the risk), and the AGCs were incrementally associated with subsequent development of a culprit lesion as a cause of an ACS beyond the risk associated with the adverse plaque characteristics of the lesion itself on the prior CCTA.
The concepts around AGCs were established a while back using either invasive angiography or invasive intravascular imaging with IVUS or OCT at or around the time of the ACS to interrogate the vessel geometric characteristics of the culprit lesion. The strength of the current paper is the CCTA study occurring well prior to the ACS, allowing an assessment of risk prediction instead of just cross-sectional association. Perhaps most importantly regarding novelty, the use of CCTA enabled a more comprehensive analysis of adverse plaque characteristics in addition to AGCs so that their relation and independent and incremental value (which is modest, although detectable) could be assessed, enabling a very comprehensive interrogation of the coronary vessels.
The novelty here is the independence and interaction of the less-studied AGCs with the well-known adverse plaque characteristics in relation to the association with risk of a later culprit lesion causing an ACS. If these interesting findings are replicated to heighten validity, one could envision better and earlier identification of patients with stable CAD who are at a higher risk for future ACS using these CCTA concepts and targeting them for even more aggressive lipid-lowering and anti-inflammatory therapy.