Richard A Ferraro1, Alexander R van Rosendael1,2, Yao Lu3, Daniele Andreini4, Mouaz H Al-Mallah5, Filippo Cademartiri6, Kavitha Chinnaiyan7, Benjamin J W Chow8, Edoardo Conte4, Ricardo C Cury9, Gudrun Feuchtner10, Pedro de Araújo Gonçalves11, Martin Hadamitzky12, Yong-Jin Kim13, Jonathon Leipsic14, Erica Maffei15, Hugo Marques11, Fabian Plank16, Gianluca Pontone4, Gilbert L Raff7, Todd C Villines17, Sang-Eun Lee18, Subhi J Al'Aref1, Lohendran Baskaran1,19, Iksung Cho18,20, Ibrahim Danad21, Heidi Gransar22, Matthew J Budoff23, Habib Samady24, Peter H Stone25, Renu Virmani26, Jagat Narula27, Daniel S Berman28, Hyuk-Jae Chang18, Jeroen J Bax2, James K Min1, Leslee J Shaw1, Fay Y Lin1. 1. Department of Radiology, New York-Presbyterian Hospital, Weill Cornell Medicine, 413 E 69th Street, Suite 108, New York, NY 10021, USA. 2. Department of Cardiology, Leiden University Medical Center, Cardiology, Albinusdreef 2, Leiden, Zuid-Holland 2333 ZA, The Netherlands. 3. Department of Healthcare Policy and Research, New York-Presbyterian Hospital, Weill Cornell Medical College, 413 E 69th Street, Suite 108, New York, NY 10021, USA. 4. Centro Cardiologico Monzino, IRCCS, Via Carlo Parea, 4, 20138 Milano MI, Italy. 5. Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, 6565 Fannin Street, Houston, TX 77030, USA. 6. Cardiovascular Imaging Center, SDN IRCCS, via Gianturco 113, 80143 Naples, Italy. 7. Department of Cardiology, William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073, USA. 8. Department of Medicine and Radiology, University of Ottawa, 451 Smyth Rd #2044, Ottawa, ON K1H 8M5, Canada. 9. Department of Radiology, Miami Cardiac and Vascular Institute, 8900 N Kendall Dr., Miami, FL 33176, USA. 10. Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria. 11. UNICA, Unit of Cardiovascular Imaging, Hospital da Luz, Av. Lusíada 100, 1500-650 Lisbon, Portugal. 12. Department of Radiology and Nuclear Medicine, German Heart Center Munich, Lazarettstraße 36, 80636 Munich, Germany. 13. Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Seoul 110-744, Republic of South Korea. 14. Department of Medicine and Radiology, University of British Columbia, 2775 Laurel St. Vancouver, BC V5Z 1M9 Canada. 15. Department of Radiology, Area Vasta 1/ASUR Marche, Viale Federico Comandino, 70, 61029 Urbino, Italy. 16. Department of Cardiology, Innsbruck Medical University, Christoph-Probst-Platz 1, Innrain 52 A, 6020 Innsbruck, Austria. 17. Department of Medicine, University of Virginia Health System, 1215 Lee St, Charlottesville, VA 22908, USA. 18. Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Division of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, 50-1 Yonsei-Ro, Seodaemun-gu, Seoul, Seoul 120-752, Republic of South Korea. 19. National Heart Centre, 5 Hospital Dr, Singapore 169609, Singapore. 20. Chung-Ang University Hospital, Dongjak-gu, Heukseok-dong, Heukseok-ro, Seoul, 102 KR 06973, Republic of South Korea. 21. Department of Cardiology, Amsterdam University Medical Center, VU University Medical Center, De Boelelaan 1117, 1081 HV, 1VU University Medical Center, Amsterdam, The Netherlands. 22. Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Blvd, Taper 1258, Los Angeles, CA 90048, USA. 23. Department of Medicine, Los Angeles Biomedical Research Institute, 1124 W Carson St, Torrance, CA 90502, USA. 24. Division of Cardiology, Department of Medicine, Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, USA. 25. Department of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA. 26. Department of Pathology, CVPath Institute, 19 Firstfield Rd, Gaithersburg, MD 20878, USA. 27. Division of Cardiology, Department of Medicine, 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, One Gustave L Levy Place, Box 1030, New York, NY 10029, USA. 28. Department of Imaging and Medicine, Cedars Sinai Medical Center, 8705 Gracie Allen Dr, Los Angeles, CA 90048, USA.
Abstract
AIMS: High-risk plaque (HRP) and non-obstructive coronary artery disease independently predict adverse events, but their importance to future culprit lesions has not been resolved. We sought to determine in patients prior to confirmed acute coronary syndrome (ACS) the association between lesion percent diameter stenosis (%DS), and the absolute number and prevalence of HRP. The secondary objective was to examine the relative importance of non-obstructive HRP in future culprit lesions. METHODS AND RESULTS: Within the ICONIC study, a nested case-control study of patients undergoing coronary computed tomographic angiography (coronary CT), we included ACS cases with culprit lesions confirmed by invasive coronary angiography and coregistered to baseline coronary CT. Quantitative CT was used to evaluate obstructive (≥50%) and non-obstructive (<50%) diameter stenosis, with HRP defined as ≥2 features of spotty calcification, positive remodelling, or low-attenuation plaque at baseline. A total of 234 patients with downstream ACS over 54 (interquartile range 5-525.5) days exhibited 198/898 plaques with HRP on coronary CT. While HRP was less prevalent in non-obstructive (19.7%, 161/819) than obstructive lesions (46.8%, 37/79, P < 0.001), non-obstructive plaque comprised 81.3% (161/198) of HRP lesions overall. Among the 128 patients with identifiable culprit lesion precursors, the adjusted hazard ratio (HR) was 1.85 [95% confidence interval (CI) 1.26-2.72] for HRP, with no interaction between %DS and HRP (P = 0.82). Compared to non-obstructive HRP lesions, obstructive lesions without HRP exhibited a non-significant HR of 1.41 (95% CI 0.61-3.25, P = 0.42). CONCLUSIONS: While HRP is more prevalent among obstructive lesions, non-obstructive HRP lesions outnumber those that are obstructive and confer risk clinically approaching that of obstructive lesions without HRP. Published on behalf of the European Society of Cardiology. All rights reserved.
AIMS: High-risk plaque (HRP) and non-obstructive coronary artery disease independently predict adverse events, but their importance to future culprit lesions has not been resolved. We sought to determine in patients prior to confirmed acute coronary syndrome (ACS) the association between lesion percent diameter stenosis (%DS), and the absolute number and prevalence of HRP. The secondary objective was to examine the relative importance of non-obstructive HRP in future culprit lesions. METHODS AND RESULTS: Within the ICONIC study, a nested case-control study of patients undergoing coronary computed tomographic angiography (coronary CT), we included ACS cases with culprit lesions confirmed by invasive coronary angiography and coregistered to baseline coronary CT. Quantitative CT was used to evaluate obstructive (≥50%) and non-obstructive (<50%) diameter stenosis, with HRP defined as ≥2 features of spotty calcification, positive remodelling, or low-attenuation plaque at baseline. A total of 234 patients with downstream ACS over 54 (interquartile range 5-525.5) days exhibited 198/898 plaques with HRP on coronary CT. While HRP was less prevalent in non-obstructive (19.7%, 161/819) than obstructive lesions (46.8%, 37/79, P < 0.001), non-obstructive plaque comprised 81.3% (161/198) of HRP lesions overall. Among the 128 patients with identifiable culprit lesion precursors, the adjusted hazard ratio (HR) was 1.85 [95% confidence interval (CI) 1.26-2.72] for HRP, with no interaction between %DS and HRP (P = 0.82). Compared to non-obstructive HRP lesions, obstructive lesions without HRP exhibited a non-significant HR of 1.41 (95% CI 0.61-3.25, P = 0.42). CONCLUSIONS: While HRP is more prevalent among obstructive lesions, non-obstructive HRP lesions outnumber those that are obstructive and confer risk clinically approaching that of obstructive lesions without HRP. Published on behalf of the European Society of Cardiology. All rights reserved.
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