Atherosclerosis evaluation and cardiovascular risk estimation using coronary computed tomography angiography

Abstract

Clinical risk scores based on traditional risk factors of atherosclerosis correlate imprecisely to an individual's complex pathophysiological predisposition to atherosclerosis and provide limited accuracy for predicting major adverse cardiovascular events (MACE). Over the past two decades, computed tomography scanners and techniques for coronary computed tomography angiography (CCTA) analysis have substantially improved, enabling more precise atherosclerotic plaque quantification and characterization. The accuracy of CCTA for quantifying stenosis and atherosclerosis has been validated in numerous multicentre studies and has shown consistent incremental prognostic value for MACE over the clinical risk spectrum in different populations. Serial CCTA studies have advanced our understanding of vascular biology and atherosclerotic disease progression. The direct disease visualization of CCTA has the potential to be used synergistically with indirect markers of risk to significantly improve prevention of MACE, pending large-scale randomized evaluation.

Keywords: Atherosclerotic cardiovascular disease; Coronary artery disease; Coronary computed tomography angiography; Major adverse cardiovascular events; Prevention.

Graphical Abstract

Coronary computed tomography angiography (CCTA) can change the population risk-based approach to a personalized care approach and provides important clinical utility. Coronary computed tomography angiography allows for precise atherosclerotic plaque quantification and characterization, and CCTA studies have advanced our understanding of vascular biology that holds potential to change our population risk-based approach to a personalized care approach. Coronary computed tomography angiography also provides clinical utility for assessment of drug efficacy and as a gatekeeper to cardiac catheterization lab. AUC, area under the curve; CAD, coronary artery disease; CCTA, coronary computed tomography angiography; HDL-C, high-density lipoprotein cholesterol.

Figure 1

Prevalence and hazard of coronary computed tomography angiography characteristics in symptomatic patients. Estimates of the relative hazards and prevalence of different CCTA characteristics, derived from different large studies in symptomatic patients.^, 3VD, three-vessel disease; CACS, coronary artery calcium score; CCTA, coronary computed tomography angiography; DS, diameter stenosis; HR, hazard ratio; HRP+, presence of high-risk plaque; LAP, low-attenuation plaque; LM, left main disease; MACE, major adverse cardiovascular event; non-obs. CAD, non-obstructive coronary artery disease; PAV, percent atheroma volume; TPV, total plaque volume

Figure 2

Relationship between coronary computed tomography angiography-derived plaque burden and 10-year risk for cardiovascular events. Ten-year risk of cardiovascular events according to different plaque stages based on percent atheroma volume. The risk for cardiovascular events increases with increasing plaque volume. ASCVD, atherosclerotic cardiovascular disease; CAD, coronary artery disease; CVD, cardiovascular disease; CCTA, coronary computed tomography angiography; PAV, percent atheroma volume. Adapted from Nurmohamed et al.

Figure 3

Example of 1K plaque. The artery segment in the left panel (A) shows two lesions composed of 1K plaque without non-calcified plaque. Cross-sectional examples are shown with 1K plaque. The artery segment in (B) shows calcifications between 351 and 1000 HU intermingled in non-calcified plaque. Two cross-sections show 351 to 1000 HU calcium together with fibrous plaque tissue. HU, Hounsfield units. Adapted from van Rosendael et al.

Figure 4

Multidimensional role of coronary computed tomography (CT) in coronary artery disease. Coronary CT angiography can refine risk stratification, determine need for medical therapy, can reduce unnecessary invasive coronary angiography and determined the need for revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)

Figure 5

Comparison of population risk-based prevention with personalized prevention strategies using coronary computed tomography angiography. Differences in a population-based approach based on risk factors (e.g. commonly used ASCVD risk scores) and a personalized care strategy based on the actual disease phenotype observed with CCTA. In a population-based risk factor strategy, patients are treated based on the presence of risk factors. If the presence of risk factors aligns with the presence of atherosclerosis, patients are treated appropriately. In a population-based risk factor strategy, patients without risk factors but with presence of atherosclerosis are missed, while patients with risk factors but without atherosclerosis (above a certain age threshold) are unnecessarily treated. In a personalized care strategy with CCTA, patients can receive appropriate therapy based on their individual atherosclerosis phenotype. ASCVD, atherosclerotic cardiovascular disease; CCTA, coronary computed tomography angiography; Tx, treatment