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Residual Risk in Non-ST-Segment Elevation Acute Coronary Syndrome: Quantitative Plaque Analysis at Coronary CT
Zhong-Fei Lu1, Wei-Hua Yin1, U Joseph Schoepf1
1From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.).
Insights
Quantitative coronary CT angiography (CCTA) can identify lipid-rich plaques in non-ST-segment elevation acute coronary syndrome (NSTE ACS). This analysis helps predict major adverse cardiovascular events (MACEs) in patients with NSTE ACS.
Area of Science:
- Cardiovascular Imaging
- Interventional Cardiology
- Radiology
Background:
- Lipid-rich plaques are linked to adverse cardiovascular events in non-ST-segment elevation acute coronary syndrome (NSTE ACS).
- Prognostic implications of coronary CT angiography (CCTA) in NSTE ACS require further investigation.
- Intravascular imaging has shown associations between lipid-rich plaques and cardiovascular events.
Purpose of the Study:
- To evaluate if quantitative CCTA measures of plaque lipid content predict future major adverse cardiovascular events (MACEs) in NSTE ACS patients.
- To assess the prognostic value of lipid core burden and volume in nonrevascularized plaques.
- To determine the association between CCTA-derived lipid metrics and nonrevascularized plaque-related MACEs.
Main Methods:
- Prospective, multicenter cohort study of 342 NSTE ACS patients undergoing CCTA before invasive coronary angiography.
- Lipid core defined as plaque areas <30 HU; MACEs included cardiac death, MI, unstable angina hospitalization, and revascularization.
- Follow-up for at least 3 years, with multivariable Cox regression analysis for lipid core burden and volume predictors.
Main Results:
- The 4-year MACE rate was 23.9%.
- Lipid core burden was an independent predictor of MACEs at the participant level (HR 12.6, threshold 2.8%).
- Lipid core burden (HR 12.1, threshold 7.2%) and volume (HR 11.0, threshold 10.1 mm3) predicted MACEs at the plaque level.
Conclusions:
- Quantitative CCTA analysis of plaque lipid content independently predicts higher risk for future MACEs in NSTE ACS.
- CCTA-derived lipid metrics can identify patients and plaques at increased risk for adverse cardiovascular events.
- This study highlights the prognostic value of assessing plaque composition with CCTA in NSTE ACS.
Abstract:
Background Lipid-rich plaques detected with intravascular imaging are associated with adverse cardiovascular events in patients with non-ST-segment elevation (NSTE) acute coronary syndrome (ACS). But evidence about the prognostic implication of coronary CT angiography (CCTA) in NSTE ACS is limited. Purpose To assess whether quantitative variables at CCTA that reflect lipid content in nonrevascularized plaques in individuals with NSTE ACS might be predictors of subsequent nonrevascularized plaque-related major adverse cardiovascular events (MACEs). Materials and Methods In this multicenter prospective cohort study, from November 2017 to January 2019, individuals diagnosed with NSTE ACS (excluding those at very high risk) were enrolled and underwent CCTA before invasive coronary angiography (ICA) within 1 day. Lipid core was defined as areas with attenuation less than 30 HU in plaques. MACEs were defined as cardiac death, myocardial infarction, hospitalization for unstable angina, and revascularization. Participants were followed up at 6 months, 12 months, and annually thereafter for at least 3 years (ending by July 2022). Multivariable analysis using Cox proportional hazards regression models was performed to determine the association between lipid core burden, lipid core volume, and future nonrevascularized plaque-related MACEs at both the participant and plaque levels. Results A total of 342 participants (mean age, 57.9 years ± 11.1 [SD]; 263 male) were included for analysis with a median follow-up period of 4.0 years (IQR, 3.6-4.4 years). The 4-year nonrevascularized plaque-related MACE rate was 23.9% (95% CI: 19.1, 28.5). Lipid core burden (hazard ratio [HR], 12.6; 95% CI: 4.6, 34.3) was an independent predictor at the participant level, with an optimum threshold of 2.8%. Lipid core burden (HR, 12.1; 95% CI: 6.6, 22.3) and volume (HR, 11.0; 95% CI: 6.5, 18.4) were independent predictors at the plaque level, with an optimum threshold of 7.2% and 10.1 mm3, respectively. Conclusion In NSTE ACS, quantitative analysis of plaque lipid content at CCTA independently predicted participants and plaques at higher risk for future nonrevascularized plaque-related MACEs. Chinese Clinical Trial Registry no. ChiCTR1800018661 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Tavakoli and Duman in this issue.
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