Relationship of coronary artery plaque composition to coronary artery stenosis severity: Results from the prospective multicenter ACCURACY trial
Introduction
Coronary computed tomographic angiography (CCTA) has emerged as accurate non-invasive method for the detection and exclusion of obstructive coronary artery disease (CAD) [1], [2], [3]. Further, CCTA permits evaluation of numerous other coronary artery plaque characteristics, including plaque compositions, which are generally graded as non-calcified, calcified and mixed [4]. Classification of plaques by CCTA based upon composition has important clinical implications, with increasing numbers of mixed plaques possessing thin cap fibroatheroma, associated with myocardial ischemia and predictive of adverse CAD prognosis [5], [6], [7], [8]. To date, however, the relationship of plaque composition by CCTA to luminal diameter stenosis severity remains unknown.
The aim of this prospective multi-center study was to determine the relationship of coronary artery plaque composition by CCTA to QCA-confirmed luminal diameter stenosis severity in chest pain subjects without known CAD. We evaluated these relationships on a per-segment and per-patient basis.
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Patients
The Assessment by coronary computed tomographic angiography of individuals undergoing invasive coronary angiography (ACCURACY) study was designed to prospectively evaluate adult subjects with chest pain who were being clinically referred for non-emergent invasive coronary angiography (ICA) [1]. Potential study subjects were screened and enrolled by a site research coordinator if they met all of the inclusion and none of the exclusion criteria. Study subjects were asked to undergo a research
Patient characteristics
230 subjects met study eligibility criteria, including completion of both CCTA and ICA (mean interval 5.9 ± 4.3 days). The mean Agatston score was 284 ± 538 (Table 1).
Segment-based evaluation
Amongst 2954 coronary segments identified, consensus was achieved for at least 2 of 3 readers in 98.8% (2918/2954). Amongst CCTA-identified plaques, mixed plaques were the most common (43.9%; 319/727), followed by calcified (28.3%; 206/727) and non-calcified (27.8%; 202/727) plaques. There was a significant relationship between plaque
Discussion
These results of the ACCURACY trial represent the first prospective multicenter data relating plaque composition by CCTA to QCA-confirmed measures of luminal diameter stenosis severity. The current data demonstrate a strong association between the presence of mixed plaque composition to obstructive coronary artery stenosis at a per-segment and per-patient level. In addition, these data establish a negative association between calcified plaque composition and stenosis severity, particularly on a
Conclusion
In this multicenter trial of chest pain patients without known CAD, QCA-confirmed obstructive coronary stenosis was associated with presence of mixed plaque composition by CCTA at both the per-segment and the per-patient levels. Coronary artery segments exhibiting calcified plaque were rarely associated with obstructive coronary stenosis.
Acknowledgements
GE Healthcare sponsored and coordinated the study to ensure that good clinical practices and data integrity were achieved (ClinicalTrials.gov Identifier: NCT00348569). In addition, GE Healthcare provided recommendations for computed tomography X-ray dosing and injection protocols, site training, and logistical support for data transfer from individual sites to the core laboratories. GE Healthcare allowed the Principal Investigators to direct the data analysis, manuscript preparation, and review
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