RESUMEN
The three most common mechanisms of thrombosis in acute coronary syndrome (ACS) are plaque rupture, plaque erosion and calcified nodule. Plaque erosion occurs over an intact fibrous cap, commonly over pathological intimal thickening (PIT) rather than thin cap fibroatheroma (TCFA), and is more common among younger and female patients.1 A very rare mechanism of ACS is spontaneous coronary artery dissection (SCAD), resulting from the formation of an intramural hematoma and/or intimal disruption.2 We present a case of sudden coronary death with the appearance of SCAD on coronary computed tomography angiography (CCTA).
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Síndrome Coronario Agudo , Enfermedad de la Arteria Coronaria , Placa Aterosclerótica , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/etiología , Síndrome Coronario Agudo/patología , Angiografía por Tomografía Computarizada , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/patología , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/patología , Femenino , Humanos , Placa Aterosclerótica/patología , Valor Predictivo de las Pruebas , Rotura Espontánea/patología , Tomografía de Coherencia Óptica/métodosRESUMEN
INTRODUCTION: Despite their significance, the prevalence and the incidence of vulnerable plaques in coronary arteries, as well as their natural history, remain poorly known. AIM: To evaluate the prevalence, incidence and evolution of napkin-ring sign (NRS), and to establish factors associated with its presence, progression, or regression, in patients with suspected coronary artery disease (CAD). MATERIAL AND METHODS: The study is based on a single-center prospective registry. Eighty-nine patients with suspected CAD underwent two computed tomography angiography (CTA) examinations within an interval of at least 24 months. High-risk plaque was defined by the presence of a low-attenuation area adjacent to the coronary lumen, surrounded by a ring of higher attenuation - NRS. RESULTS: At the baseline 53 NRS were observed in 22 (25%) patients, 7 (8%) patients had single NRS and 15 (17%) had multiple NRS. After the follow-up period, there were 68 NRS in 32 patients. In 18 patients progression was observed with 23 additional NRS. Presence of single NRS and diabetes were independent predictors of NRS progression. CONCLUSIONS: The number of NRS plaque tends to increase over time in patients with suspected CAD. The progression may be predicted by the presence of diabetes or single NRS.
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Angiografía por Tomografía Computarizada , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Placa Aterosclerótica , Calcificación Vascular/diagnóstico por imagen , Anciano , Enfermedad de la Arteria Coronaria/patología , Vasos Coronarios/patología , Errores Diagnósticos , Humanos , Masculino , Valor Predictivo de las Pruebas , Calcificación Vascular/patologíaRESUMEN
OBJECTIVES: Current clinical models predict the pre-test probability of obstructive coronary artery disease, but these models do not predict the presence of high-risk plaques. Thus the objective of this study was to propose a model to predict high-risk plaque assessed by coronary computed tomography (CT) angiography. METHODS: This study was a retrospective cross-sectional study. A clinical model was derived from 2392 patients and verified by 733 patients who underwent coronary CT suspected of coronary artery disease. High-risk plaque was defined as a plaque with positive remodeling (remodeling index>1.1), low attenuation (<30Hounsfield units) and napkin-ring sign. The risk score was calculated from the following 6 variables with a maximum of 24 points: age, sex, hemoglobin A1c, systolic blood pressure, high-density lipoprotein and smoking status. RESULTS: The proportion of patients with high-risk plaque was 11% and 17% in the derivation and validation cohort, respectively. The area under the receiver operation characteristic curve was 0.71 (95% confidence interval (CI): 0.68 to 0.74) in the derivation cohort and 0.75 (95% CI: 0.70 to 0.79) in the validation cohort. The frequency of high-risk plaques was 4% in the low-risk group (≤8 points) while it was 53% in the high-risk group (≥17 points) of the derivation cohort. CONCLUSIONS: We propose a scoring system to detect high-risk plaque assessed by coronary CT. Patients in the high-risk group have a high prevalence of high-risk plaque and might benefit from lipid lowering therapy.
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Angiografía por Tomografía Computarizada/métodos , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Placa Aterosclerótica/diagnóstico por imagen , Factores de Edad , Anciano , Área Bajo la Curva , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/fisiopatología , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Placa Aterosclerótica/fisiopatología , Valor Predictivo de las Pruebas , Pronóstico , Reproducibilidad de los Resultados , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores Sexuales , Análisis de SupervivenciaRESUMEN
AIM: To investigate the relationship between coronary calcium score (CCS) and vulnerable plaque/significant stenosis using coronary computed tomographic angiography (CCTA). METHODS: CCTA was performed in 651 patients and these patients were divided into the four groups (CCS 0, 1-100, 101-400 and > 400). We studied the incidence of high-risk plaque, including positive remodeling, low attenuation plaque, spotty calcification, and napkin-ring sign, and significant stenosis in each group. RESULTS: High-risk plaque was found in 1.3%, 10.1%, 13.3% and 13.4% of patients with CCS 0, 1-100, 101-400 and > 400, respectively (P < 0.001). The difference was only significant for patients with zero CCS. The incidence of significant stenosis was 0.6%, 7.6%, 13.3% and 26.9% for each patient group, respectively (P < 0.001), which represented a significant stepwise increase as CCS increased. The combined incidence of high-risk plaque and significant stenosis was 1.9%, 17.7%, 26.9% and 40.3% in each patient group, respectively (P < 0.001), again representing a significant stepwise increase with CCS. The rate of major coronary event was 0%, 4.0%, 7.9% and 17.2% in each patient group, respectively (P < 0.001), another significant stepwise increase as CCS increased. CONCLUSION: Stepwise increased risk of coronary events associated with increasing CCS is caused by increasing incidence of significant stenosis, while that of high-risk plaque remains the same.
RESUMEN
BACKGROUND: Although napkin-ring sign (NRS) plaques assessed by multidetector computed tomography (MDCT) is identified as a high-risk feature, the detailed morphological features are still unknown. The purpose of this study was to elucidate the morphological features of the MDCT-assessed NRS using intravascular ultrasound (IVUS). METHODS: We evaluated 204 plaques in 193 patients with non-ST-elevation acute coronary syndrome who were diagnosed using 128-slice MDCT and were assessed using IVUS prior to coronary intervention. Morphology was compared between plaques with and without MDCT-assessed NRS. Severe IVUS-assessed attenuation was defined as an attenuation angle >180°. RESULTS: NRS was detected in 49 lesions. MDCT-assessed plaque attenuation was lower (p<0.0001), and cross-sectional plaque areas at lesion sites, remodeling index, and the prevalence of positive remodeling were greater, in lesions with NRS (p<0.005, p<0.0001, and p<0.0001, respectively). Furthermore, the IVUS-assessed remodeling index and prevalence of severe attenuation and speckled echo appearance were significantly greater in lesions with NRS (p<0.01, p<0.0001, and p<0.0001, respectively). Using multivariate analysis, IVUS-assessed speckled echo appearance was identified as an independent predictor of MDCT-assessed NRS (odds ratio, 3.59; 95% confidence interval, 1.49-8.66; p<0.005). CONCLUSION: MDCT assessment of NRS may be associated with larger heterogeneous necrotic cores and greater positive remodeling.
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Angiografía Coronaria/métodos , Vasos Coronarios/diagnóstico por imagen , Tomografía Computarizada Multidetector/métodos , Infarto del Miocardio sin Elevación del ST/diagnóstico por imagen , Placa Aterosclerótica/diagnóstico por imagen , Ultrasonografía Intervencional/métodos , Anciano , Anciano de 80 o más Años , Vasos Coronarios/patología , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio sin Elevación del ST/patología , Placa Aterosclerótica/patologíaRESUMEN
OBJECTIVE: We sought to assess the incremental prognostic value of quantitative plaque characterization beyond established CT risk scores. BACKGROUND: Several plaque characteristics detectable by coronary computed tomographic angiography (coronary CTA) are thought to be indicative of vulnerable plaques and subsequent cardiac events, particularly low attenuation plaque volume (LAPV), positive remodeling and the napkin-ring sign which is high density vascular adhesion with a small center of low density. It is unknown how quantitative plaque assessment can contribute to the long-term prediction of cardiovascular events in relation to established CT risk scores such as the calcium score or Segment Stenosis Score (SSS). METHODS: In 1168 consecutive patients with suspected coronary artery disease (CAD), calcium score measurement and coronary plaque characterization was performed comprising the presence of calcified, non-calcified, and partially calcified plaques on a per-segment basis. In all non-calcified or partially calcified plaques, semi-automated plaque analysis was performed to quantify low attenuation plaque volume (density <30 HU), total non-calcified plaque volume (<150 HU, TNCPV) and remodeling index. The presence of the napkin-ring sign was assessed visually. The study endpoint was the occurrence of major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction and coronary revascularization more than 90 days after coronary CTA. RESULTS: During a clinical follow up of 5.7 years, MACE was observed in 46 patients (3.9%). All plaque characteristics were associated with MACE. The strongest association was observed for LAPV (HR 1.12, p < 0.0001). LAPV showed incremental prognostic value in a stepwise multivariable model including the Morise Score for clinical risk, calcium score and SSS (p = 0.036). CONCLUSION: LAPV, TPV, PR and presence of the napkin-ring sign are predictors of MACE independently of clinical risk presentation. LAPV carries slight additional prognostic information beyond the calcium score and conventional coronary CTA analysis. It may therefore improve risk prediction after CT imaging.