To determine the rate of subsequent invasive coronary angiography (ICA) and revascularization in relation to computed tomography coronary angiography (CTA) results. In addition, independent... Show moreTo determine the rate of subsequent invasive coronary angiography (ICA) and revascularization in relation to computed tomography coronary angiography (CTA) results. In addition, independent determinants of subsequent ICA and revascularization were evaluated. CTA studies were performed using a 64-row (n = 413) or 320-row (n = 224) multidetector scanner. The presence and severity of CAD were determined on CTA. Following CTA, patients were followed up for 1 year for the occurrence of ICA and revascularization. A total of 637 patients (296 male, 56 ± 12 years) were enrolled and 578 CTA investigations were available for analysis. In patients with significant CAD on CTA, subsequent ICA rate was 76 %. Among patients with non-significant CAD on CTA, subsequent ICA rate was 20 % and among patients with normal CTA results, subsequent ICA rate was 5.7 % (p < 0.001). Of patients with significant CAD on CTA, revascularization rate was 47 %, as compared to a revascularization rate of 0.6 % in patients with non-significant CAD on CTA and no revascularizations in patients with a normal CTA results (p < 0.001). Significant CAD on CTA and significant three-vessel or left main disease on CTA were identified as the strongest independent predictors of ICA and revascularization. CTA results are strong and independent determinants of subsequent ICA and revascularization. Consequently, CTA has the potential to serve as a gatekeeper for ICA to identify patients who are most likely to benefit from revascularization and exclude patients who can safely avoid ICA. Show less
Velzen, J.E. van; Graaf, M.A. de; Ciarka, A.; Graaf, F.R. de; Schalij, M.J.; Kroft, L.J.; ... ; Wall, E.E. van der 2012
Previous angiographic studies have shown that almost two-thirds of vulnerable plaques are located in non-obstructive lesions. Possibly, the maximum necrotic core (Max NC) area is not always... Show morePrevious angiographic studies have shown that almost two-thirds of vulnerable plaques are located in non-obstructive lesions. Possibly, the maximum necrotic core (Max NC) area is not always identical to the site of most severe stenosis. Therefore, the purpose of this study was to evaluate the potential difference in location between the maximum necrotic core area and the site of most severe narrowing as assessed by virtual histology intravascular ultrasound (VH IVUS). Overall, 77 patients (139 vessels) underwent VH IVUS. The Max NC site was defined as the cross section with the largest necrotic core area per vessel. The site of most severe narrowing was defined as the minimum lumen area (MLA). Per vessel, the distance from both the Max NC site and MLA site to the origo of the coronary artery was evaluated. In addition, the presence of a virtual histology-thin cap fibroatheroma (VH-TCFA) was assessed. The mean difference (mm) between the MLA site and Max NC site was 10.8 ± 20.6 mm (p < 0.001). Interestingly, the Max NC site was located at the MLA site in seven vessels (5%) and proximally to the MLA site in 92 vessels (66%). Importantly, a higher percentage of VH-TCFA was demonstrated at the Max NC site as compared to the MLA site (24 vs. 9%, p < 0.001). In conclusion, the present findings demonstrate that the Max NC area is rarely at the site of most severe narrowing. Most often, the Max NC area is located proximal to the site of most severe narrowing. Show less
Velzen, J.E. van; Graaf, M.A. de; Ciarka, A.; Graaf, F.R. de; Schalij, M.J.; Kroft, L.J.; ... ; Wall, E.E. van der 2012
Multidetector computed tomography angiography (CTA) provides information on plaque extent and stenosis in the coronary wall. More accurate lesion assessment may be feasible with CTA as compared to... Show moreMultidetector computed tomography angiography (CTA) provides information on plaque extent and stenosis in the coronary wall. More accurate lesion assessment may be feasible with CTA as compared to invasive coronary angiography (ICA). Accordingly, lesion length assessment was compared between ICA and CTA in patients referred for CTA who underwent subsequent percutaneous coronary intervention (PCI). 89 patients clinically referred for CTA were subsequently referred for ICA and PCI. On CTA, lesion length was measured from the proximal to the distal shoulder of the plaque. Quantitative coronary angiography (QCA) was performed to analyze lesion length. Stent length was recorded for each lesion. In total, 119 lesions were retrospectively identified. Mean lesion length on CTA was 21.4 ± 8.4 mm and on QCA 12.6 ± 6.1 mm. Mean stent length deployed was 17.4 ± 5.3 mm. Lesion length on CTA was significantly longer than on QCA (difference 8.8 ± 6.7 mm, P < 0.001). Moreover, lesion length visualized on CTA was also significantly longer than mean stent length (CTA lesion length-stent length was 4.2 ± 8.7 mm, P < 0.001). Lesion length assessed by CTA is longer than that assessed by ICA. Possibly, CTA provides more accurate lesion length assessment than ICA and may facilitate improved guidance of percutaneous treatment of coronary lesions. Show less
Graaf, F.R. de; Velzen, J.E. van; Witkowska, A.J.; Schuijf, J.D.; Bijl, N. van der; Kroft, L.J.; ... ; Wall, E.E. van der 2011
A considerable number of patients with an acute coronary syndrome (ACS) who present with a 0 or low calcium score (CS) still demonstrate coronary artery disease (CAD) and significant stenosis. The... Show moreA considerable number of patients with an acute coronary syndrome (ACS) who present with a 0 or low calcium score (CS) still demonstrate coronary artery disease (CAD) and significant stenosis. The aim of the present study was to evaluate the relation between the CS and the degree and character of atherosclerosis in patients with suspected ACS versus patients with stable CAD obtained by computed tomography angiography and virtual histology intravascular ultrasound (VH IVUS). Overall 112 patients were studied, 53 with ACS and 59 with stable CAD. Calcium scoring and computed tomography angiography were performed and followed by VH IVUS. On computed tomography angiography each segment was evaluated for plaque and classified as noncalcified, mixed, or calcified. Vulnerable plaque characteristics on VH IVUS were defined by percent necrotic core and presence of thin-cap fibroatheroma. If the CS was 0, patients with ACS had a higher mean number of plaques (5.0 +/- 2.0 vs 2.0 +/- 1.9, p <0.05) and noncalcified plaques (4.6 +/- 3.5 vs 1.3 +/- 1.9, p <0.05) on computed tomography angiography than those with stable CAD. If the CS was 0, VH IVUS demonstrated that patients with ACS had a larger amount of necrotic core area (0.58 +/- 0.73 vs 0.22 +/- 0.43 mm(2), p <0.05) and a higher mean number of thin-cap fibroatheromas (0.6 +/- 0.7 vs 0.1 +/- 0.3, p <0.05) than patients with stable CAD. In conclusion, even in the presence of a 0 CS, patients with ACS have increased plaque burden and increased vulnerability compared to patients with stable CAD. Therefore, absence of coronary calcification does not exclude the presence of clinically relevant and potentially vulnerable atherosclerotic plaque burden in patients with ACS. (C) 2011 Elsevier Inc. All rights reserved. (Am J Cardiol 2011;108:658-664) Show less
Coronary computed tomographic angiography allows direct evaluation of the vessel wall and thus positive remodeling, which is a marker of vulnerability. The purpose of this study was to assess the... Show moreCoronary computed tomographic angiography allows direct evaluation of the vessel wall and thus positive remodeling, which is a marker of vulnerability. The purpose of this study was to assess the association between positive remodeling on computed tomography angiogram (CTA) and vulnerable plaque characteristics on virtual histologic intravascular ultrasound (VH IVUS) images. Forty-five patients (78% men, 58 +/- 11 years old) underwent computed tomographic angiography followed by VH IVUS. On CIA, the remodeling index was determined for each lesion by a blinded observer using quantitative analysis. Positive remodeling was defined based on a remodeling index >= 1.0. Percent necrotic core and presence of thin-capped fibroatheroma (TCFA) were used as markers for plaque vulnerability on VH IVUS images. Ninety-nine atherosclerotic plaques were evaluated, of which 37 lesions (37.4%) were identified as having positive remodeling on CTA. Higher levels of plaque vulnerability were identified in lesions with positive remodeling compared to lesions without positive remodeling. Percent necrotic core was significantly higher in lesions with positive remodeling (15.7 +/- 7.8%) compared to lesions without this characteristic (10.2 +/- 7.2%, p <0.001). Furthermore, significantly more TCFA lesions were identified in positively remodeled lesions (n = 16, 43.2%) than in lesions without positive remodeling (n = 3, 4.8%, p <0.001). In conclusion, lesions with positive remodeling on CIA are associated with increased levels of plaque vulnerability on VH IVUS images including a higher percent necrotic core and a higher prevalence of TCFA. Thus evaluation of remodeling on CTA may provide a valuable marker for plaque vulnerability. (C) 2011 Elsevier Inc. All rights reserved. (Am J Cardiol 2011;107:1725-1729) Show less
Aims The positive predictive value of multidetector computed tomography angiography (CTA) for detecting significant stenosis remains limited. Possibly CTA may be more accurate in the evaluation of... Show moreAims The positive predictive value of multidetector computed tomography angiography (CTA) for detecting significant stenosis remains limited. Possibly CTA may be more accurate in the evaluation of atherosclerosis rather than in the evaluation of stenosis severity. However, a comprehensive assessment of the diagnostic performance of CTA in comparison with both conventional coronary angiography (CCA) and intravascular ultrasound (IVUS) is lacking. Therefore, the aim of the study was to systematically investigate the diagnostic performance of CTA for two endpoints, namely detecting significant stenosis (using CCA as the reference standard) vs. detecting the presence of atherosclerosis (using IVUS as the reference of standard). Methods and results A total of 100 patients underwent CTA followed by both CCA and IVUS. Only those segments in which IVUS imaging was performed were included for CTA and quantitative coronary angiography (QCA) analysis. On CTA, each segment was evaluated for significant stenosis (defined as >= 50% luminal narrowing), on CCA significant stenosis was defined as a stenosis >= 50%. Second, on CTA, each segment was evaluated for atherosclerotic plaque; atherosclerosis on IVUS was defined as a plaque burden of >= 40% cross-sectional area. CTA correctly ruled out significant stenosis in 53 of 53 (100%) patients. However, nine patients (19%) were incorrectly diagnosed as having significant lesions on CTA resulting in sensitivity, specificity, positive, and negative predictive values of 100, 85, 81, and 100%. CTA correctly ruled out the presence of atherosclerosis in 7 patients (100%) and correctly identified the presence of atherosclerosis in 93 patients (100%). No patients were incorrectly classified, resulting in sensitivity, specificity, positive, and negative predictive values of 100%. Conclusions The present study is the first to confirm using both CCA and IVUS that the diagnostic performance of CTA is superior in the evaluation of the presence or the absence of atherosclerosis when compared with the evaluation of significant stenosis. Show less
Wall, E.E. van der; Graaf, F.R. de; Velzen, J.E. van; Jukema, J.W.; Bax, J.J.; Schuijf, J.D. 2011
The purpose of this study was to determine the prognostic value of computed tomography coronary angiography (CTA)-derived left ventricular (LV) function analysis and to assess its incremental... Show moreThe purpose of this study was to determine the prognostic value of computed tomography coronary angiography (CTA)-derived left ventricular (LV) function analysis and to assess its incremental prognostic value over the detection of significant stenosis using CTA. In 728 patients (400 males, mean age 55 +/- A 12 years) with known or suspected CAD, the presence of significant stenosis (a parts per thousand yen 50% stenosis) and LV function were assessed using CTA. LV end-systolic volume (LVESV), LV end-diastolic volume (LVEDV), and LV ejection fraction (LVEF) were calculated. LV function was assessed as a continuous variable and using cutoff values (LVEDV > 215 mL, LVESV > 90 mL, LVEF < 49%). The following events were combined in a composite end-point: all-cause mortality, non-fatal myocardial infarction, and unstable angina pectoris requiring hospitalization. On CTA, a significant stenosis was observed in 221 patients (30%). During follow-up [median 765 days, 25-75th percentile: 493-978] an event occurred in 45 patients (6.2%). After multivariate correction for clinical risk factors and CTA, LVEF < 49% and LVESV > 90 mL were independent predictors of events with an incremental prognostic value over clinical risk factors and CTA. The present results suggest that LV function analysis provides independent and incremental prognostic information beyond anatomic assessment of CAD using CTA. Show less
Wall, E.E. van der; Graaf, F.R. de; Velzen, J.E. van; Jukema, J.W.; Schuijf, J.D.; Bax, J.J. 2010
