Noninvasive detection of coronary atherosclerotic plaque by multidetector row computed tomography

Coronary artery disease continues to be one of the leading causes of death and disability around the globe, challenging the efficacy of currently applied schemes to predict the risk for future coronary events. In fact, algorithms such as the Framingham risk score that are based on traditional risk factors like hypertension and dyslipidemia are not very sensitive, leaving a majority of the population at intermediate risk.

Advances in multidetector computed tomography (MDCT) technology with submillimeter slice collimation (approximately 0.6 mm) and high temporal resolution now permit contrast-enhanced imaging of the coronary artery lumen and wall in a single breath hold. The current generation of MDCT provided in-plane resolution of 0.5 mm and a temporal resolution of 210 ms. The simultaneous acquisition of 16/64 parallel cross-sections reduces image acquisition time to about 10-20s using 60-80 ml of contrast agents to opacify the coronary artery lumen. CT imaging for coronary calcification is an established method with low radiation exposure. The amount of calcification is expressed as an Agatston Score (AS).

The presence and amount of coronary calcification significantly increases the relative risk for future coronary events, independent from traditional risk factors (risk ratio 8.7 [95% Cl, 2.7-28.1]). Especially, individuals with a high AS (>400) who are at intermediate 10-y Framingham event risk may benefit from this additional risk stratification. However, calcification is rarely present in children and adolescents. However, there is a growing body of evidence suggesting that contrast-enhanced MDCT can detect both calcified and noncalcified plaques with high sensitivity and specificity for the detection of plaques > 0.5 mm when compared to intravascular ultrasound. Moreover, initial data suggest that plaque characteristics such as plaque area, volume, quantify and coronary plaque remodeling index can be quantified in good agreement with IVUS. The composition of noncalcified plaque may be further stratified into predominantly fibrous or lipid-rich plaque. Noncalcified plaque may be present already in children and adolescents with multiple risk factors.

The available data indicate that high resolution MDCT can reliably detect, quantify and characterize calcified and noncalcified coronary atherosclerotic plaque. With MDCT, we now have a unique opportunity to study the natural history and response to therapy of noncalcified coronary plaques, which may be already present in obese children or children with multiple risk factors.