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Multicenter Study
. 2019 Oct;12(10):2000-2010.
doi: 10.1016/j.jcmg.2018.11.032. Epub 2019 Feb 13.

Peri-Coronary Adipose Tissue Density Is Associated With 18F-Sodium Fluoride Coronary Uptake in Stable Patients With High-Risk Plaques

Jacek Kwiecinski  1 , Damini Dey  2 , Sebastien Cadet  2 , Sang-Eun Lee  3 , Yuka Otaki  2 , Phi T Huynh  2 , Mhairi K Doris  4 , Evann Eisenberg  2 , Mijin Yun  3 , Maurits A Jansen  4 , Michelle C Williams  4 , Balaji K Tamarappoo  2 , John D Friedman  2 , Marc R Dweck  2 , David E Newby  4 , Hyuk-Jae Chang  3 , Piotr J Slomka  2 , Daniel S Berman  5
Affiliations
Multicenter Study

Peri-Coronary Adipose Tissue Density Is Associated With 18F-Sodium Fluoride Coronary Uptake in Stable Patients With High-Risk Plaques

Jacek Kwiecinski et al. JACC Cardiovasc Imaging. 2019 Oct.

Abstract

Objectives: This study aimed to assess the association between increased lesion peri-coronary adipose tissue (PCAT) density and coronary 18F-sodium fluoride (18F-NaF) uptake on positron emission tomography (PET) in stable patients with high-risk coronary plaques (HRPs) shown on coronary computed tomography angiography (CTA).

Background: Coronary 18F-NaF uptake reflects the rate of calcification of coronary atherosclerotic plaque. Increased PCAT density is associated with vascular inflammation. Currently, the relationship between increased PCAT density and 18F-NaF uptake in stable patients with HRPs on coronary CTA has not been characterized.

Methods: Patients who underwent coronary CTA were screened for HRP, which was defined by 3 concurrent plaque features: positive remodeling; low attenuation plaque (LAP) (<30 Hounsfield units [HU]) and spotty calcification; and obstructive coronary stenosis ≥50% (plaque volume >100 mm3). Patients with HRPs were recruited to undergo 18F-NaF PET/CT. In lesions with stenosis ≥25%, quantitative plaque analysis, mean PCAT density, maximal coronary motion-corrected 18F-NaF standard uptake values (SUVmax), and target-to-background ratios (TBR) were measured.

Results: Forty-one patients (age 65 ± 6 years; 68% men) were recruited. Fifty-one lesions in 23 patients (56%) showed increased coronary 18F-NaF activity. Lesions with 18F-NaF uptake had higher surrounding PCAT density than those without 18F-NaF uptake (-73 HU; interquartile range -79 to -68 HU vs. -86 HU; interquartile range -94 to -80 HU; p < 0.001). 18F-NaF TBR and SUVmax were correlated with PCAT density (r = 0.63 and r = 0.68, respectively; all p < 0.001). On adjusted multiple regression analysis, increased lesion PCAT density and LAP volume were associated with 18F-NaF TBR (β = 0.25; 95% confidence interval: 0.17 to 0.34; p < 0.001 for PCAT, and β = 0.07; 95% confidence interval: 0.03 to 0.11; p = 0.002 for LAP).

Conclusions: In patients with HRP features on coronary CTA, increased density of PCAT was associated with focal 18F-NaF PET uptake. Simultaneous assessment of these imaging biomarkers by 18F-NaF PET and CTA might refine cardiovascular risk prediction in stable patients with HRP features.

Keywords: (18)F-sodium fluoride; PET/CT; coronary computed tomography angiography; coronary imaging; high-risk plaque; peri-coronary adipose tissue density.

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Figures

Figure 1.
Figure 1.. Pericoronary adipose tissue density and 18F-NaF uptake.
Lesions with PET tracer uptake had higher PCAT density than those without (−73.2 [−78.7, −68.5] vs −86.3 [−93.8, −79.8] HU, p<0.001) (A). There was moderate correlation between lesion PCAT density and SUVmax (r=0.63, p<0.001) (B) and a stronger association between PCAT density and TBR (r=0.68, p<0.001) (C). HU - Hounsfield Units; PCAT - pericoronary adipose tissue; SUVmax -maximum standard uptake values; TBR - target to background ratio
Figure 2.
Figure 2.. Case illustrations of coronary CTA and assessment of 18F-NaF uptake and PCAT attenuation in high-risk plaques.
Patient 1: 53-year-old male with a RCA plaque with positive remodeling (green arrow) (A), focal 18F-NaF uptake with increased target to background ratio (TBR) of 1.73 (B), and increased PCAT attenuation (mean PCAT density [−76.7 HU]) (C). Patient 2: 66-year-old male with a LAD lesion with low attenuation plaque (green arrow) (E), focal 18F-NaF uptake with increased TBR of 1.87 (F), and increased PCAT attenuation (mean PCAT density of [−74.8 HU] (F). Patient 3: 54-year-old male with a LAD lesion with low attenuation plaque (green arrow) (G), focal 18F-NaF uptake with increased TBR of 2.28 (H), and increased PCAT attenuation (mean PCAT density [−73.6 HU]) (I). HU - Hounsfield Units; LAD - left anterior descending; PCAT - pericoronary adipose tissue; RCA - right coronary artery; SUVmax -maximum standard uptake values; TBR - target to background ratio
Figure 3.
Figure 3.. Examples of 18F-NaF uptake in six patients with high risk plaque characteristics.
Focal uptake in the proximal LAD (A, B), left main and LAD (C), proximal (D) and distal (E) RCA and proximal LCX. LAD - left anterior descending; LCX - left circumflex; RCA - right coronary artery
Figure 4.
Figure 4.. Pericoronary adipose tissue density evaluation of plaques in the LAD (A-C) and RCA (D-F).
Multiplanar reconstructed (A, D), cross-sectional (B, E) images and histograms presenting pericoronary adipose tissue assessment. Cylindrical volumes of interest are drawn automatically radially from the vessel wall within the distance equal to the artery diameter (red, orange, yellow on MPR [A, D] and cross-sectional [B, E] images). Only pixels with attenuation: −190 to −30 are considered as adipose tissue. Myocardium adjacent to the vessel wall and coronary branches were automatically excluded (panels A, B and D, E). The mean adipose tissue density within the entire volume of interest was used for analysis. LAD - left anterior descending; PCAT – pericoronary adipose tissue RCA - right coronary artery
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