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Multicenter Study
. 2022 Jun;15(6):1078-1088.
doi: 10.1016/j.jcmg.2022.02.004. Epub 2022 Apr 13.

Pericoronary Adipose Tissue Attenuation, Low-Attenuation Plaque Burden, and 5-Year Risk of Myocardial Infarction

Evangelos Tzolos  1 , Michelle C Williams  2 , Priscilla McElhinney  3 , Andrew Lin  3 , Kajetan Grodecki  3 , Guadalupe Flores Tomasino  3 , Sebastien Cadet  3 , Jacek Kwiecinski  4 , Mhairi Doris  1 , Philip D Adamson  1 , Alastair J Moss  1 , Shirjel Alam  1 , Amanda Hunter  1 , Anoop S V Shah  5 , Nicholas L Mills  1 , Tania Pawade  1 , Chengjia Wang  1 , Jonathan R Weir-McCall  6 , Giles Roditi  7 , Edwin J R van Beek  2 , Leslee J Shaw  8 , Edward D Nicol  9 , Daniel S Berman  3 , Piotr J Slomka  3 , Marc R Dweck  1 , David E Newby  1 , Damini Dey  10
Affiliations
Multicenter Study

Pericoronary Adipose Tissue Attenuation, Low-Attenuation Plaque Burden, and 5-Year Risk of Myocardial Infarction

Evangelos Tzolos et al. JACC Cardiovasc Imaging. 2022 Jun.

Abstract

Background: Pericoronary adipose tissue (PCAT) attenuation and low-attenuation noncalcified plaque (LAP) burden can both predict outcomes.

Objectives: This study sought to assess the relative and additive values of PCAT attenuation and LAP to predict future risk of myocardial infarction.

Methods: In a post hoc analysis of the multicenter SCOT-HEART (Scottish Computed Tomography of the Heart) trial, the authors investigated the relationships between the future risk of fatal or nonfatal myocardial infarction and PCAT attenuation measured from coronary computed tomography angiography (CTA) using multivariable Cox regression models including plaque burden, obstructive coronary disease, and cardiac risk score (incorporating age, sex, diabetes, smoking, hypertension, hyperlipidemia, and family history).

Results: In 1,697 evaluable participants (age: 58 ± 10 years), there were 37 myocardial infarctions after a median follow-up of 4.7 years. Mean PCAT was -76 ± 8 HU and median LAP burden was 4.20% (IQR: 0%-6.86%). PCAT attenuation of the right coronary artery (RCA) was predictive of myocardial infarction (HR: 1.55; P = 0.017, per 1 SD increment) with an optimum threshold of -70.5 HU (HR: 2.45; P = 0.01). In multivariable analysis, adding PCAT-RCA of ≥-70.5 HU to an LAP burden of >4% (the optimum threshold for future myocardial infarction; HR: 4.87; P < 0.0001) led to improved prediction of future myocardial infarction (HR: 11.7; P < 0.0001). LAP burden showed higher area under the curve compared to PCAT attenuation for the prediction of myocardial infarction (AUC = 0.71 [95% CI: 0.62-0.80] vs AUC = 0.64 [95% CI: 0.54-0.74]; P < 0.001), with increased area under the curve when the 2 metrics are combined (AUC = 0.75 [95% CI: 0.65-0.85]; P = 0.037).

Conclusion: Coronary CTA-defined LAP burden and PCAT attenuation have marked and complementary predictive value for the risk of fatal or nonfatal myocardial infarction.

Keywords: computed tomography angiography; coronary artery disease; low-attenuation noncalcified plaque burden; noncalcified plaque burden; pericoronary adipose tissue; risk stratification.

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Conflict of interest statement

Funding Support and Author Disclosures This trial was funded by The Chief Scientist Office of the Scottish Government Health and Social Care Directorates (CZH/4/588), with supplementary awards from Edinburgh and Lothian’s Health Foundation Trust and the Heart Diseases Research Fund. Dr Williams, (FS/ICRF/20/26002, FS/11/014, CH/09/002), Dr Newby (CH/09/002, RG/16/10/32375, RE/18/5/34216), and Dr Dweck (FS/14/78/31020) are supported by the British Heart Foundation. Dr Williams was supported by The Chief Scientist Office of the Scottish Government Health (PCL/17/04). Dr Newby is the recipient of a Wellcome Trust Senior Investigator Award (WT103782AIA). Dr van Beek is supported by the Scottish Imaging Network: A Platform of Scientific Excellence (SINAPSE). Dr Mills is supported by the British Heart Foundation through the award of the Butler Senior Clinical Research Fellowship and a Programme Grant (FS/16/14/32023, RG/20/10/34966). Dr Adamson is supported by a National Heart Foundation of New Zealand Senior Fellowship (1844). Dr Dweck is supported by the Sir Jules Thorn Biomedical Research Award 2015 (15/JTA). The Royal Bank of Scotland supported the provision of the 320-multidetector computed tomography for National Health Service Lothian and the University of Edinburgh. The Edinburgh Imaging Facility, The Queen's Medical Research Institute (Edinburgh) is supported by the National Health Service Research Scotland through the National Health Service Lothian Health Board. The Clinical Research Facility Glasgow and Clinical Research Facility Tayside are supported by National Health Service Research Scotland. This work is supported in part by the National Institutes of Health/National Heart, Lung, and Blood Institute grants 1R01HL148787-01A1 and 1R01HL151266. Drs Lin and Grodecki, Priscilla McElhinney, Sebastien Cadet, and Dr Dey are supported by National Institutes of Health/National Heart, Lung, and Blood Institute grant 1R01HL148787-01A1. This work is also supported in part by the Miriam and Sheldon G. Adelson Medical Research Foundation. Sebastien Cadet, and Drs Berman, Slomka, and Dey received software royalties from Cedars-Sinai Medical Center. Drs Slomka, Berman, and Dey hold a patent (US8885905B2 in the United States and World Intellectual Property Organization patent WO2011069120A1, “Method and System for Plaque Characterization”). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Figure 1:
Figure 1:
Plaque burden (left upper panels; red is non-calcified plaque) with 3-dimensional plaque composition (right upper panels; orange is low attenuation non-calcified plaque) and peri-coronary adipose tissue quantification (lower panels) and in the left anterior descending artery (A-C), the left circumflex artery (D-F) and the right coronary artery (G-I). PCAT analysis focused on the proximal right coronary artery (10–50 mm from ostium), left anterior descending coronary artery (0–40 mm from left main stem bifurcation) and left circumflex (0–40 mm from left main stem bifurcation). We considered PCAT attenuation (reported in Hounsfield units [HU]) as the average attenuation of all adipose tissue containing voxels (range −190 HU to −30 HU) within an outer radial distance from the vessel wall of 3 mm.
Figure 2:
Figure 2:
Peri-coronary adipose tissue of the right coronary artery (PCAT-RCA) and fatal or nonfatal myocardial infarction. Cumulative incidence of fatal or nonfatal myocardial infarction in patients with and without PCAT-RCA ≥ −70.5 HU.
Figure 3:
Figure 3:
Cumulative incidence of fatal or nonfatal myocardial infarction in patients with and without peri-coronary adipose tissue of the right coronary artery (PCAT-RCA) ≥ −70.5 HU and with and without low-attenuation plaque burden (LAP) above 4%. Patients with LAP burden>4 % and PCAT-RCA ≥−70.5 HU (purple line) were at the greatest risk of myocardial infarction (HR 11.7, 95% CI 3.3 to 40.9, p<0.0001), followed by people with LAP burden >4 % and PCAT-RCA <−70.5 HU (green line); HR= 5.1 (1.5 −17.7), p<0.0001.
Figure 4:
Figure 4:. Comparison of receiver operator characteristics (at 5 years) and respective area under the curve (AUC).
Low-attenuation plaque (LAP) burden is a stronger predictor comparted to peri-coronary adipose tissue of the right coronary artery (PCAT-RCA); p<0.001. The combination of the two metrics increase the AUC from 0.71 for LAP alone to 0.75(ΔAUC= 0.04, p=0.037).
Central Illustration.
Central Illustration.. Pericoronary Adipose Tissue Attenuation and Low Attenuation Plaque Burden Provide Complementary Predictive Value for 5-year Risk of Fatal or Nonfatal Myocardial Infarction in Patients with Suspected Coronary Artery Disease
(Left – Top) Forrest plot of the multivariable analysis for the prediction of myocardial infarction. Low-attenuation Plaque (LAP) Burden and Pericoronary Adipose Tissue Attenuation (PCAT) are the only independent predictors of fatal or nonfatal Myocardial Infarction. (Left-Bottom) Bar graph with 95% confidence interval error bars comparing the area under the receiver operator characteristic curve (AUC) for the prediction of myocardial. Low-attenuation plaque burden showed higher area-under-the-curve (AUC) compared to PCAT-RCA attenuation for the prediction for myocardial infarction [0.71 (0.62–0.80) versus 0.64 (0.54–0.74); p<0.001], with the combination of both parameters yielding the highest AUC [0.75 (0.65–0.85); p=0.037] (Right) Based on the Youden’s index of the ROC curves, the optimal cut-off of the right coronary artery PCAT attenuation was −70.5 HU for the primary endpoint of fatal or non-fatal myocardial infarction. Patients with PCAT-RCA above ≥−70.5 HU were nearly 2.5 times more likely to suffer a myocardial infarction (HR 2.45, 95% CI 1.23 to 4.80; p=0.001). Patients with low-attenuation plaque burden (greater than 4%) were nearly 5 times more likely to suffer a myocardial infarction (HR 4.87, 95% CI 2.03 to 11.78, p<0.0001). When the two metrics were combined, patients with both low-attenuation plaque burden >4% and PCAT-RCA ≥−70.5 HU were at the greatest risk of myocardial infarction (HR 11.7, 95% CI 3.3 to 40.9, p<0.0001)
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References

    1. Chang HJ, Lin FY, Lee SE et al. Coronary Atherosclerotic Precursors of Acute Coronary Syndromes. J Am Coll Cardiol 2018;71:2511–2522. - PMC - PubMed
    1. Maddox TM, Stanislawski MA, Grunwald GK et al. Nonobstructive coronary artery disease and risk of myocardial infarction. JAMA 2014;312:1754–63. - PMC - PubMed
    1. Williams MC, Kwiecinski J, Doris M et al. Low-Attenuation Noncalcified Plaque on Coronary Computed Tomography Angiography Predicts Myocardial Infarction. Circulation 2020;141:1452–1462. - PMC - PubMed
    1. Ross R. Atherosclerosis — An Inflammatory Disease. New England Journal of Medicine 1999;340:115–126. - PubMed
    1. van der Wal AC, Becker AE, van der Loos CM, Das PK. Site of intimal rupture or erosion of thrombosed coronary atherosclerotic plaques is characterized by an inflammatory process irrespective of the dominant plaque morphology. Circulation 1994;89:36–44. - PubMed

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