The Atherosclerotic Profile of a Young Symptomatic Population between 19 and 49 Years: Coronary Computed Tomography Angiography or Coronary Artery Calcium Score?

Abstract

(1) Background: Whether coronary computed tomography angiography (CTA) or the coronary artery calcium score (CACS) should be used for diagnosis of coronary heart disease, is an open debate. The aim of our study was to compare the atherosclerotic profile by coronary CTA in a young symptomatic high-risk population (age, 19-49 years) in comparison with the coronary artery calcium score (CACS). (2) Methods: 1137 symptomatic high-risk patients between 19-49 years (mean age, 42.4 y) who underwent coronary CTA and CACS were stratified into six age groups. CTA-analysis included stenosis severity and high-risk-plaque criteria (3) Results: Atherosclerosis was more often detected based on CTA than based on CACS (45 vs. 27%; p < 0.001), 50% stenosis in 13.6% and high-risk plaque in 17.7%. Prevalence of atherosclerosis was low and not different between CACS and CTA in the youngest age groups (19-30 y: 5.2 and 6.4% and 30-35 y: 10.6 and 16%). In patients older than >35 years, the rate of atherosclerosis based on CTA increased (p = 0.004, OR: 2.8, 95%CI:1.45-5.89); and was higher by CTA as compared to CACS (34.9 vs. 16.7%; p < 0.001), with a superior performance of CTA. In patients older than 35 years, stenosis severity (p = 0.002) and >50% stenosis increased from 2.6 to 12.5% (p < 0.001). High-risk plaque prevalence increased from 6.4 to 26.5%. The distribution of high-risk plaque between CACS 0 and >0.1 AU was similar among all age groups, with an increasing proportion in CACS > 0.1 AU with age. A total of 24.9% of CACS 0 patients had coronary artery disease based on CTA, 4.4% > 50% stenosis and 11.5% had high-risk plaque. (4) Conclusions: In a symptomatic young high-risk population older than 35 years, CTA performed superior than CACS. In patients aged 19-35 years, the rate of atherosclerosis was similar and low based on both modalities. CACS 0 did not rule out coronary artery disease in a young high-risk population.

Keywords: atherosclerosis; computed tomography; coronary arteries; imaging; young high-risk population.

Figure 1

(a) A 30 year-old-male with diabetes since 14 years, presenting with ketoacidosis to our ED. Hs-Troponin (49 ng/dL) and HBA1c (11.2%) were elevated. CTA (A) showed a non-calcified lesion (white arrows) in the proximal LAD with positive remodeling (“high-risk- plaque”—HRP) with quantitative 3.15 mm³ lipid-rich necrotic core plaque volume (LAP < 30 HU) (b) based on CTA. CACS was 0. There was no calcific plaque components by CTA (a). Manual contour editing (b) was performed if automated tracing of lesion borders was inaccurate (mid cMPR and right cMPR) (SyngoVIA^TM Frontier Research, Siemens Healthineers): VRT (left) and MPR (mid and right). (b) cMPR and quantitative plaque analysis.

Figure 2

(a) Atherosclerosis based on the coronary artery calcium score (CACS) compared to coronary CTA. Atherosclerosis prevalence increased from 16% to 34.9% in patients older than 35 years based on CTA (p = 0.004) (b). N = percentage (%).

Figure 3

Obstructive coronary artery disease (>50% stenosis) based on CTA: Prevalence increased in patients older than 35 years of age (p < 0.001).

Figure 4

Vulnerable plaque features (high-risk-plaque—“HRP”) increased continuously with age.

Figure 5

(a) High-risk plaque (HRP) in patients without coronary calcium (CACS 0) compared to those with coronary calcium (CACS > 0.1 AU). (b–d). The distribution of high-risk-plaque (HRP) in CACS zero compared to positive CACS > 0.1 AU among different age groups was not different with 63 vs. 36% in patients between 19 and 35 years (b,c). In patients >35 years of age, there was a trend towards an increasing prevalence of HRP in those with positive CACS > 0.1 AU (d,e).