The value of cardiac CT based inflammatory risk assessment in predicting cardiovascular events: a case report

Vascular inflammation plays a critical role in the development of coronary artery disease (CAD). Measurement of coronary inflammation from coronary computed tomography angiography (CCTA) using the perivascular fat attenuation index (FAI) Score could provide unique prognostic information and guide the clinical management of patients. In this context, we also refer to an artificial intelligence-based risk prediction tool (AI-Risk algorithm), which integrates FAI Score with clinical risk factors and plaque burden to estimate the long-term probability of a fatal cardiac event.

A 69-year-old male presented with symptoms of new onset angina. Past medical history included coronary artery bypass grafting (CABG) in 2001. Initial evaluation with CCTA showed patent arterial graft to left anterior descending (LAD) artery and two occluded venous grafts to obtuse marginal and diagonal branches, respectively, were identified. The non-grafted right coronary artery (RCA) was non-obstructive with moderate mid-vessel stenosis and the patient was discharged on optimal medical therapy. However, the patient was intolerant to statin. Eight years later, the patient was admitted to the hospital with a non-ST segment elevation myocardial infarction (NSTEMI) and the invasive coronary angiography showed occlusion of the non-grafted RCA. After few months of guidelines directed medical therapy, the patient developed progressive heart failure due to ischaemic cardiomyopathy and mitral regurgitation that led to his death. Retrospective perivascular FAI measurement of the non-grafted RCA captured the significantly elevated residual inflammatory risk.

The utilization of perivascular FAI Score and AI-Risk algorithm to capture inflammatory risk and predict future events beyond the current clinical risk stratification and CCTA interpretation, especially in the absence of obstructive CAD, could offer an important adjunct to current strategies in preventive cardiology, pending further validation. In this case report, our patient's management plan could have been adjusted had these technologies been available during initial evaluation, and the high inflammatory burden of the non-grafted RCA was timely captured.