Computed tomographic angiography in coronary artery disease.

by Computed tomographic angiography in coronary artery disease e-edition April 2023 Patrick W. Serruys1*, MD, PhD; Nozomi Kotoku1, MD; Bjarne L. Nørgaard2, MD, PhD; Scot Garg3, MD, PhD; Koen Nieman4, MD, PhD; Marc R. Dweck5, MD, PhD; Jeroen J. Bax6,7, MD, PhD; Juhani Knuuti6,7, MD, PhD; Jagat Narula8, MD, PhD; Divaka Perera9, MD, MB, BChir; Charles A. Taylor10, PhD; Jonathon A. Leipsic11, MD; Edward D. Nicol12,13, MD; Nicolo Piazza14, MD, PhD; Carl J. Schultz15,16, MD, PhD; Kakuya Kitagawa17, MD, PhD; Bernard De Bruyne18,19, MD, PhD; Carlos Collet18, MD, PhD; Kaoru Tanaka20, MD, PhD; Saima Mushtaq21, MD; Marta Belmonte18, MD; Darius Dudek22, MD, PhD; Adriana Zlahoda-Huzior23,24, MSc; Shengxian Tu25, PhD; William Wijns1,26, MD, PhD; Faisal Sharif1, MD, PhD; Matthew J. Budoff27, MD; Johan de Mey20, MD, PhD; Daniele Andreini28,29, MD, PhD; Yoshinobu Onuma1, MD, PhD EuroIntervention 2023;18:e1307- e1327 published online State-of-the-Art The authors’ affiliations can be found in the Appendix paragraph. P.W. Serruys and N. Kotoku contributed equally to this work. This paper also includes supplementary data published online at: https://eurointervention.pcronline.com/doi/10.4244/EIJ-D-22-00776 KEYWORDS • fractional flow reserve • MSCT • non-invasive imaging Abstract Coronary computed tomographic angiography (CCTA) is becoming the first-line investigation for establishing the presence of coronary artery disease and, with fractional flow reserve (FFRCT), its haemodynamic significance. In patients without significant epicardial obstruction, its role is either to rule out atherosclerosis or to detect subclinical plaque that should be monitored for plaque progression/regression following prevention therapy and provide risk classification. Ischaemic non-obstructive coronary arteries are also expected to be assessed by non-invasive imaging, including CCTA. In patients with significant epicardial obstruction, CCTA can assist in planning revascularisation by determining the disease complexity, vessel size, lesion length and tissue composition of the atherosclerotic plaque, as well as the best fluoroscopic viewing angle; it may also help in selecting adjunctive percutaneous devices (e.g., rotational atherectomy) and in determining the best landing zone for stents or bypass grafts. © Europa Digital & Publishing 2023. All rights reserved. DOI: 10.4244/EIJ-D-22-00776 *Corresponding author: Cardiovascular Research Centre for Advanced Imaging, Core Lab (CORRIB) Research Centre, University of Galway, University Road, Galway H91 TK33, Ireland. E-mail: SUBMITTED ON 03/09/2022 - REVISION RECEIVED ON 20/10/2022 - ACCEPTED ON 14/11/2022 e1307 EuroIntervention 2023;18:e1307- e1327 Abbreviations ACS acute coronary syndrome CABG coronary artery bypass graft CAC coronary artery calcium CAD coronary artery disease CCTA coronary computed tomographic angiography CTP computed tomography perfusion FFR fractional flow reserve FFRCT fractional flow reserve derived from coronary computed tomographic angiography ICA invasive coronary angiography LAP low-attenuation plaque MACE major adverse cardiac events MI myocardial infarction MPI myocardial perfusion imaging NOCAD non-obstructive coronary artery disease PCI percutaneous coronary intervention PET positron emission tomography PTP pretest probability UHR-CT ultra-high spatial resolution computed tomography Introduction During the nineties, coronary computed tomographic angiography (CCTA) emerged as a promising non-invasive imaging tool to diagnose coronary artery disease (CAD)1, and two decades later, it has gained prominence as a first-line investigation in diagnosis and decision-making (Central illustration, Supplementary Figure 1)1,2. CAD phenotypes may be viewed as a pyramid of multiple layers of increasing anatomical complexity3. At the bottom are subjects with normal epicardial conductance vessels who have no atherosclerotic plaque and an excellent prognosis. Above them are patients with non-obstructive coronary plaque who have an increased risk of myocardial infarction (MI) and next, patients with progressive increases in plaque burden. Patients with normal coronary arteries or non-obstructive plaque may have structural or functional coronary microvascular dysfunction (CMD) that can lead to anginal symptoms with its two corollary syndromes (INOCA and ANOCA, i.e., ischaemia/angina with non-obstructive coronary arteries). Notably, “evidence of impaired coronary microvascular function should be present” with or without ischaemia4. ù PRETEST PROBABILITY FOR OBSTRUCTIVE CAD AND DIAGNOSTIC CCTA The application of the pretest probability (PTP) for significant obstructive CAD (as determined by invasive coronary angiography [ICA] and fractional flow reserve [FFR]) based on age, sex, and the nature of symptoms underwent a major revision in the 2019 European Society of Cardiology (ESC) Guidelines for the diagnosis and management of chronic coronary syndromes (CCS)5. The PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial showed that in patients with a PTP <15%, the annual risk of cardiovascular death or MI was <1%6. e1308 The SCOT-HEART (Scottish Computed Tomography of the Heart) trial confirmed that the 2019 ESC estimates of PTP based on ICA and FFR were broadly similar to the prevalence observed on CCTA in the trial cohort7, although it tended to underestimate the real prevalence, or alternatively, CCTA might overestimate the CAD (Supplementary Figure 2A). The rates of 5-year cardiac death or non-fatal MI were 4.1%, 1.5% and 1.4% in patients with a PTP >15%, 5-15% and <5%, respectively (p<0.001 between groups) (Supplementary Figure 2B). On the other hand, the results of the Western Denmark Heart Registry, including 23,759 symptomatic patients, challenge the traditional dichotomous definition of CAD as “obstructive” or “non-obstructive” for identifying truly high-risk patients8. Major adverse cardiac events (MACE; MI, stroke, and all-cause death) at 4-year follow-up increased stepwise with both higher coronary artery calcium (CAC) scores and the number of vessels with obstructive disease detected by CCTA. Of note, when stratified into 5 groups according to CAC scores, the presence of obstructive CAD was not associated with a higher risk of MACE than the presence of non-obstructive CAD (NOCAD)8. Previously, the term “known CAD” had been used to define patients with a significant obstructive stenosis (i.e., ≥50%). In the recent American College of Cardiology (ACC)/American Heart Association (AHA) Chest Pain Guideline, the term “known CAD” was applied to those patients with prior anatomical testing (ICA or CCTA) with identified non-obstructive atherosclerotic plaque and obstructive CAD9. It was recognised as a “departure from convention” to ensure that those with lesser degrees of stenosis, who do not require revascularisation but who would benefit from optimised prevention therapy, do not get overlooked. STRUCTU (...truncated)