Hyuk-Jae Chang1, Fay Y Lin2, Sang-Eun Lee1, Daniele Andreini3, Jeroen Bax4, Filippo Cademartiri5, Kavitha Chinnaiyan6, Benjamin J W Chow7, Edoardo Conte3, Ricardo C Cury8, Gudrun Feuchtner9, Martin Hadamitzky10, Yong-Jin Kim11, Jonathon Leipsic12, Erica Maffei13, Hugo Marques14, Fabian Plank9, Gianluca Pontone3, Gilbert L Raff6, Alexander R van Rosendael4, Todd C Villines15, Harald G Weirich9, Subhi J Al'Aref2, Lohendran Baskaran2, Iksung Cho16, Ibrahim Danad17, Donghee Han18, Ran Heo19, Ji Hyun Lee18, Asim Rivzi20, Wijnand J Stuijfzand2, Heidi Gransar21, Yao Lu2, Ji Min Sung1, Hyung-Bok Park1, Daniel S Berman21, Matthew J Budoff22, Habib Samady23, Leslee J Shaw23, Peter H Stone24, Renu Virmani25, Jagat Narula26, James K Min27. 1. Division of Cardiology, Severance Cardiovascular Hospital, Integrative Cardiovascular Imaging Research Center, Yonsei University College of Medicine, Seoul, South Korea. 2. Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York. 3. Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy. 4. Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, the Netherlands. 5. Cardiovascular Imaging Center, SDN IRCCS, Naples, Italy. 6. Department of Cardiology, William Beaumont Hospital, Royal Oaks, Michigan. 7. Department of Medicine and Radiology, University of Ottawa, Ottawa, Ontario, Canada. 8. Baptist Cardiac and Vascular Institute, Miami, Florida. 9. Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria. 10. Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany. 11. Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea. 12. Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada. 13. Department of Radiology, Area Vasta 1/ASUR Marche, Urbino, Italy. 14. UNICA, Unit of Cardiovascular Imaging, Hospital da Luz, Lisboa, Portugal. 15. Cardiology Service, Walter Reed National Military Center, Bethesda, Maryland. 16. Division of Cardiology, Severance Cardiovascular Hospital, Integrative Cardiovascular Imaging Research Center, Yonsei University College of Medicine, Seoul, South Korea; Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York; Chung-Ang University Hospital, Seoul, South Korea. 17. VU University Medical Center, Amsterdam, the Netherlands. 18. Division of Cardiology, Severance Cardiovascular Hospital, Integrative Cardiovascular Imaging Research Center, Yonsei University College of Medicine, Seoul, South Korea; Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York. 19. Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea. 20. Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York; Department of Radiology, Mayo Clinic, Rochester, Minnesota. 21. Department of Imaging and Medicine, Cedars Sinai Medical Center, Los Angeles, California. 22. Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, California. 23. Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia. 24. Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts. 25. CVPath Institute, Gaithersburg, Maryland. 26. Icahn School of Medicine at Mount Sinai, Mount Sinai Heart, Zena and Michael A. Wiener Cardiovascular Institute, and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, New York, New York. 27. Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York. Electronic address: jkm2001@med.cornell.edu.
Abstract
BACKGROUND: The association of atherosclerotic features with first acute coronary syndromes (ACS) has not accounted for plaque burden. OBJECTIVES: The purpose of this study was to identify atherosclerotic features associated with precursors of ACS. METHODS: 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). RESULTS: 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 mm3 fibrofatty plaque, 95% CI: 1.000 to 1.003; 1.593 per mm3 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. CONCLUSIONS: 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. Published by Elsevier Inc.
BACKGROUND: The association of atherosclerotic features with first acute coronary syndromes (ACS) has not accounted for plaque burden. OBJECTIVES: The purpose of this study was to identify atherosclerotic features associated with precursors of ACS. METHODS: 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). RESULTS: 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 mm3 fibrofatty plaque, 95% CI: 1.000 to 1.003; 1.593 per mm3 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. CONCLUSIONS: 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. Published by Elsevier Inc.
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