CT Imaging of the Vulnerable Plaque
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Acute coronary syndromes are most often the result of vulnerable atherosclerotic plaque events. Plaques events occur when intimal fibroatheroma in the coronary artery wall becomes vulnerable to erosion or rupture. Such vulnerable plaques can be distinguished from quiescent atheroma by features that have been defined through histopathology and invasive imaging. A challenge for coronary CT angiography has been to identify vulnerable plaques non-invasively. Were this possible, CT angiography could offer comprehensive vessel assessment including stenosis severity and plaque characteristics with the hope of reducing acute coronary events through timely intervention. Over the past decade, advances in invasive imaging techniques have enabled unstable coronary plaques to be accessed more readily. In this fashion it has been possible to correlate invasive appearances to CT angiographic findings in an unprecedented manner. Several CT defined plaque characteristic have now been described to reliably identify unstable plaques. Retrospective studies have demonstrated the utility of these plaque features to predict future acute coronary events. If these can be confirmed in prospective studies, the intrinsic benefits of non-invasive imaging will position coronary CT angiography firmly in our armamentarium to image coronary arteries and help prevent acute coronary events.
KeywordsAcute coronary syndromes CT angiography Imaging
Compliance with Ethical Standards
Conflict of Interest
Gary R. Small declares no potential conflicts of interest.
Benjamin J. W. Chow reports grants from TeraRecon and CV Diagnostix.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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- 3.Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: task force for the Management of Acute Coronary Syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(3):267–315.CrossRefPubMedGoogle Scholar
- 12.Wu X, Mintz GS, Xu K, Lansky AJ, Witzenbichler B, Guagliumi G, et al. The relationship between attenuated plaque identified by intravascular ultrasound and no-reflow after stenting in acute myocardial infarction: the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial. JACC Cardiovasc Interv. 2011;4(5):495–502.CrossRefPubMedGoogle Scholar
- 16.Kitagawa T, Yamamoto H, Ohhashi N, Okimoto T, Horiguchi J, Hirai N, et al. Comprehensive evaluation of noncalcified coronary plaque characteristics detected using 64-slice computed tomography in patients with proven or suspected coronary artery disease. Am Heart J. 2007;154(6):1191–8.CrossRefPubMedGoogle Scholar
- 18.Ozaki Y, Okumura M, Ismail TF, Motoyama S, Naruse H, Hattori K, et al. Coronary CT angiographic characteristics of culprit lesions in acute coronary syndromes not related to plaque rupture as defined by optical coherence tomography and angioscopy. Eur Heart J. 2011;32(22):2814–23.CrossRefPubMedGoogle Scholar
- 19.•• Maurovich-Horvat P, Ferencik M, Voros S, Merkely B, Hoffmann U. Comprehensive plaque assessment by coronary CT angiography. Nat Rev Cardiol. 2014;11(7):390–402. Excellently written, thorough review by active researchers in the field of CT vulnerable plaque imagingCrossRefPubMedPubMedCentralGoogle Scholar
- 20.Narula J, Nakano M, Virmani R, Kolodgie FD, Petersen R, Newcomb R, et al. Histopathologic characteristics of atherosclerotic coronary disease and implications of the findings for the invasive and noninvasive detection of vulnerable plaques. J Am Coll Cardiol. 2013;61(10):1041–51.CrossRefPubMedPubMedCentralGoogle Scholar
- 23.Takamura K, Fujimoto S, Kondo T, Hiki M, Kawaguchi Y, Kato E et al. Incremental prognostic value of coronary computed tomography angiography: high-risk plaque characteristics in asymptomatic patients. J Atheroscler Thromb 2017. https://doi.org/10.5551/jat.39115.
- 26.Ferencik M, Mayrhofer T, Puchner SB, Lu MT, Maurovich-Horvat P, Liu T, et al. Computed tomography-based high-risk coronary plaque score to predict acute coronary syndrome among patients with acute chest pain—results from the ROMICAT II trial. J Cardiovasc Comput Tomogr. 2015;9(6):538–45.CrossRefPubMedPubMedCentralGoogle Scholar
- 30.• Joshi NV, Vesey AT, Williams MC, Shah AS, Calvert PA, Craighead FH, et al. 18F-fluoride positron emission tomography for identification of ruptured and high-risk coronary atherosclerotic plaques: a prospective clinical trial. Lancet. 2014;383(9918):705–13. An important “landmark” study likely to lead to further work to determine the pathphysiology of calcification of atherosclerotic plaquesCrossRefPubMedGoogle Scholar
- 31.Hadamitzky M, Achenbach S, Al-Mallah M, Berman D, Budoff M, Cademartiri F, et al. Optimized prognostic score for coronary computed tomographic angiography: results from the CONFIRM registry (COronary CT angiography EvaluatioN for clinical outcomes: an InteRnational multicenter registry). J Am Coll Cardiol. 2013;62(5):468–76.CrossRefPubMedGoogle Scholar
- 34.van Velzen JE, de Graaf FR, de Graaf MA, Schuijf JD, Kroft LJ, de Roos A, et al. Comprehensive assessment of spotty calcifications on computed tomography angiography: comparison to plaque characteristics on intravascular ultrasound with radiofrequency backscatter analysis. J Nucl Cardiol. 2011;18(5):893–903.CrossRefPubMedPubMedCentralGoogle Scholar
- 37.Pijls NH, Fearon WF, Tonino PA, Siebert U, Ikeno F, Bornschein B, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (fractional flow reserve versus angiography for multivessel evaluation) study. J Am Coll Cardiol. 2010;56(3):177–84.CrossRefPubMedGoogle Scholar
- 38.Kini AS, Baber U, Kovacic JC, Limaye A, Ali ZA, Sweeny J, et al. Changes in plaque lipid content after short-term intensive versus standard statin therapy: the YELLOW trial (reduction in yellow plaque by aggressive lipid-lowering therapy). J Am Coll Cardiol. 2013;62(1):21–9.CrossRefPubMedGoogle Scholar
- 39.Hachamovitch R, Rozanski A, Shaw LJ, Stone GW, Thomson LE, Friedman JD, et al. Impact of ischaemia and scar on the therapeutic benefit derived from myocardial revascularization vs. medical therapy among patients undergoing stress-rest myocardial perfusion scintigraphy. Eur Heart J. 2011;32(8):1012–24.CrossRefPubMedGoogle Scholar
- 40.Versteeg D, Hoefer IE, Schoneveld AH, de Kleijn DP, Busser E, Strijder C, et al. Monocyte toll-like receptor 2 and 4 responses and expression following percutaneous coronary intervention: association with lesion stenosis and fractional flow reserve. Heart. 2008;94(6):770–6.CrossRefPubMedPubMedCentralGoogle Scholar
- 43.Nakanishi R, Matsumoto S, Alani A, Li D, Kitslaar PH, Broersen A, et al. Diagnostic performance of transluminal attenuation gradient and fractional flow reserve by coronary computed tomographic angiography (FFRCT) compared to invasive FFR: a sub-group analysis from the DISCOVER-FLOW and DeFACTO studies. Int J Cardiovasc Imaging. 2015;31(6):1251–9.CrossRefPubMedGoogle Scholar
- 47.Hoffmann U, Bamberg F, Chae CU, Nichols JH, Rogers IS, Seneviratne SK, et al. Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (rule out myocardial infarction using computer assisted tomography) trial. J Am Coll Cardiol. 2009;53(18):1642–50.CrossRefPubMedPubMedCentralGoogle Scholar
- 49.Ferencik M, Schlett CL, Ghoshhajra BB, Kriegel MF, Joshi SB, Maurovich-Horvat P, et al. A computed tomography-based coronary lesion score to predict acute coronary syndrome among patients with acute chest pain and significant coronary stenosis on coronary computed tomographic angiogram. Am J Cardiol. 2012;110(2):183–9.CrossRefPubMedPubMedCentralGoogle Scholar
- 50.Puchner SB, Liu T, Mayrhofer T, Truong QA, Lee H, Fleg JL, et al. High-risk plaque detected on coronary CT angiography predicts acute coronary syndromes independent of significant stenosis in acute chest pain: results from the ROMICAT-II trial. J Am Coll Cardiol. 2014;64(7):684–92.CrossRefPubMedPubMedCentralGoogle Scholar
- 56.• CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. Lancet 2015; 385(9985):2383–2391. https://doi.org/10.1016/s0140-6736(15)60291-4Innovative piece of work determining the clinical impact of CT and has led to national guideline changes in the UK.
- 57.• Williams MC, Hunter A, ASV S, Assi V, Lewis S, Smith J, et al. Use of coronary computed tomographic angiography to guide management of patients with coronary disease. J Am Coll Cardiol. 2016;67(15):1759–68. Innovative piece of work determining the clinical impact of CT and has led to national guideline changes in the UKCrossRefPubMedPubMedCentralGoogle Scholar
- 58.National Institute for Health and Clinical Excellence. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin (update) CG95. National Institute for Health and Clinical Excellence 2016.Google Scholar