plaque assessment on coronary ct angiography: is there ...• high-risk plaque features -...
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Plaque assessment on coronary CT Angiography: Is there clinical value ?
Damini Dey, PhD, FSCCT
Associate Professor and Research Scientist Director, Quantitative Image Analysis Lab
Biomedical Imaging Research Institute Cedars-Sinai Medical Center
Normal coronary CTA
43-y/o woman, family history of CAD
Normal CCTA. HR 65 bpm
100 kVp, Prospective
Radiation Dose 1.5 mSv
Warranty period for normal CTA: at least 8 years
Coronary CTA – with Atherosclerosis
Noncalcified, low-density non-calcified plaque Calcified plaque
Dangerous plaques: healing the heart National Geographic 2007
Coronary plaque
Plaque assessment from coronary CTA
• High-risk plaque features - Low-attenuation < 30 HU - Positive remodeling - Napkin-ring sign • Quantitative plaque Characterization - Low-attenuation NCP - Plaque composition, burden - Positive remodeling - Stenosis & luminal features
Motoyama et al JACC 2009 Otsuka et al JACC imaging 2013
Hell et al EHJ-CI 2017, Doris et al JCCT 2017
Quantitative plaque characterization from coronary CTA
• Standardized semi-automated software - Total plaque - Non-calcified plaque (NCP) - Calcified plaque - Low-attenuation NCP - Plaque composition - Positive outward remodeling - Stenosis
Hell et al EHJ-Cardiovascular Imaging 2017 Per-lesion, per-vessel and per-patient
Total coronary plaque volume: IVUS
Matsumoto, …,Dey et al European Radiology 2019
118 plaques in 77 patients with IVUS
R = 0.943, p<0.001
Lumen intima border
External elastic membrane
Coronary CTA
IVUS
NCP volume – blinded comparison to IVUS
Dey et al Radiology 2010
NCP volume measurement
Dey et al Radiology 2010
NCP volume measurement
116.6100.8105.9
0
50
100
150
200
IVUS Manual CCTA
APQ
NCP Volume
P=NS P=NS
Volu
me
(mm
3 )
Dey et al Radiology 2010
Comparison with IVUS: Qangio CT
Park et al Eur Radiol 2015
142 patients
with IVUS
Stenosis, MLA,
plaque volume
and burden
R = 0.91 expert R=0.84 automated
Plaque and Lesion-specific ischemia
from prospective, multicenter studies
Park et al JACC Cardiovascular Imaging 2015 Diaz Zamudio et al Radiology 2015
Gaur et al European Heart Journal 2016
Plaque composition and Lesion-specific ischemia: prospective, multicenter NXT trial
254 patients
Does plaque composition add to stenosis to predict FFR ?
Gaur et al European Heart Journal 2016
• Multicenter NXT trial • 254 patients (64% male) • 484 vessels with FFR
• NXT trial N=254 (484 vessels) analyzed for stenosis, plaque and scan findings • Highest predictive value for contrast density difference and low attenuation plaque
Machine learning for integrating plaque features to predict ischemia Machine learning for decision-making
Dey et al European Radiology 2018
*
Machine learning ischemia risk score from CTA Invasive FFR LAD = 0.73
Dey et al Artificial intelligence in Cardiovascular Imaging JACC 2019
• 2748 patients, no prior CAD • Followup of 5 ± 2 years • 32 patients with cardiac death compared to controls matched by age, gender, risk factors and symptoms • Plaque analysis by Autoplaque
Quantitative plaque: prediction of future cardiac death
Hell et al EHJ Cardiovascular Imaging 2017
Quantitative plaque: prediction of future cardiac death
Michaela Hell et al EHJ Cardiovascular Imaging 2017
Quantitative plaque: prediction of future cardiac death
Among quantitative global plaque characteristics, low-density NCP, NCP and total plaque volume as well
as CDD predict future cardiac death Michaela Hell et al EHJ Cardiovascular Imaging 2017
• ICONIC: nested case control study within CONFIRM registry (13 sites)
• Followup: 3.4 ± 2.1 years • 234 patients with ACS matched
to 234 controls – risk factors and CTA stenosis
• Plaque analysis by core lab with QAngio CT software
Quantitative plaque composition: as precursor of ACS
Chang et al JACC 2018; 71(22):2511-22
• NCP components - Necrotic core NC (-30, 30) HU - Fibrofatty FF (31-130) HU - Fibrous (131-350) HU
• High-risk noncalcified plaque – precursor of ACS
Quantitative plaque composition: as precursor of ACS
Chang et al JACC 2018; 71(22):2511-22
Quantitative plaque burden: beneficial changes with therapy ?
Plaque changes with statins
• PARADIGM cohort (13-center)
• 1255 patients serial CTA ≥ 2 years apart
• Plaque measurement by core lab QAngio CT
Lee et al JACC Cardiovascular Imaging 2018
Plaque changes with statins
Lee et al JACC Cardiovascular Imaging 2018
• PARADIGM cohort (13-center)
• 1255 patients serial CTA ≥ 2 years apart
• Plaque volume: 21% reduction
• HRP: 35% reduction
Plaque changes with statins
Lee et al JACC Cardiovascular Imaging 2018 Lee et al Circ Cardiovascular Imaging 2018
• Statins were associated with slower progression of total plaque volume, with increased plaque calcification and reduction of high-risk plaque features.
• Statins did not affect the progression of percent stenosis but induced changes in plaque composition.
• Both baseline plaque burden and its change improved prediction of MACE
Baseline Follow-up
LDL-C (mg/dl) 164 80
Plaque volume(mm3) Total plaque 581.6 408.0
Calcified plaque 67.8 63.6
Non-calcified plaque 513.9 344.3
Low-density non-calcified plaque 42.2 12.0
Baseline Follow-up
CTA plaque changes with LDL decrease ≥ 10% over 1 year 52 y.o. male with family history of CAD on statin
LAD
CP
NCP
Tamarappoo, Otaki,…, Dey, Berman et al, JCCT 2018
Otaki, Tamarappoo,…, Dey, Berman Otaki et al Atherosclerosis 2019
-60
-40
-20
0
20
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80
100
h t tih ti tih ff ti h f ti h d ti
Annu
al c
hang
e in
pla
que
volu
me
(mm
3 ) p<0.0001
p=0.0001* p=0.0001* p=0.0005* p=0.60
Plaque volume change with LDL decrease and increase All plaque components
Medium attenuation
Total plaque
Calcified plaque
Low attenuation
Medium-low attenuation
Patients with LDL decrease Patients with no LDL decrease
154 patients with serial CTA time interval 4±2 years
Non-calcified plaque
Reduction in LDL (≥10%) related to beneficial changes in plaque composition ( all components of NCP)
• CTA allows plaque characterization over the coronary tree
• Quantitative CTA measures improves prediction of lesion-specific ischemia beyond stenosis
– Low-density noncalcified plaque
– Noncalcified plaque
– Positive remodeling
– Contrast density difference
Summary: quantitative CTA
Adverse cardiac events
• More automation and standardization necessary - for faster accurate analysis
• Adverse plaque thresholds needed
• Noninvasive quantitative plaque characterization
• Improves identification of patients at risk of ischemia and cardiac events
• Improves prognostication
• Allows assessment of serial therapy: emphasis on prevention
Summary
Thank you very much
Quantitative plaque burden predict ischemia in intermediate coronary lesions ?
Diaz-Zamudio et al Radiology 2015
CTA
Automated quantification in a 65-y-o male patient. FFR (at arrow)= 0.78
DS= 34%
TP= 43%
CP= 13%
NCP= 30%
LDNCP= 2%
Quantitative plaque burden predict ischemia in intermediate coronary lesions ?
Diaz-Zamudio et al Radiology 2015
Quantitative plaque burden predict ischemia in intermediate coronary lesions ?
Diaz-Zamudio et al Radiology 2015