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Coronary Atherosclerotic Precursors of Acute Coronary Syndromes.

  • Author(s): Chang, Hyuk-Jae;
  • Lin, Fay Y;
  • Lee, Sang-Eun;
  • Andreini, Daniele;
  • Bax, Jeroen;
  • Cademartiri, Filippo;
  • Chinnaiyan, Kavitha;
  • Chow, Benjamin JW;
  • Conte, Edoardo;
  • Cury, Ricardo C;
  • Feuchtner, Gudrun;
  • Hadamitzky, Martin;
  • Kim, Yong-Jin;
  • Leipsic, Jonathon;
  • Maffei, Erica;
  • Marques, Hugo;
  • Plank, Fabian;
  • Pontone, Gianluca;
  • Raff, Gilbert L;
  • van Rosendael, Alexander R;
  • Villines, Todd C;
  • Weirich, Harald G;
  • Al'Aref, Subhi J;
  • Baskaran, Lohendran;
  • Cho, Iksung;
  • Danad, Ibrahim;
  • Han, Donghee;
  • Heo, Ran;
  • Lee, Ji Hyun;
  • Rivzi, Asim;
  • Stuijfzand, Wijnand J;
  • Gransar, Heidi;
  • Lu, Yao;
  • Sung, Ji Min;
  • Park, Hyung-Bok;
  • Berman, Daniel S;
  • Budoff, Matthew J;
  • Samady, Habib;
  • Shaw, Leslee J;
  • Stone, Peter H;
  • Virmani, Renu;
  • Narula, Jagat;
  • Min, James K
  • et al.
Abstract

BACKGROUND:The association of atherosclerotic features with first acute coronary syndromes (ACS) has not accounted for plaque burden. OBJECTIVES:The purpose of this study was to identify atherosclerotic features associated with precursors of ACS. METHODS:We performed a nested case-control study within a cohort of 25,251 patients undergoing coronary computed tomographic angiography (CTA) with follow-up over 3.4 ± 2.1 years. Patients with ACS and nonevent patients with no prior coronary artery disease (CAD) were propensity matched 1:1 for risk factors and coronary CTA-evaluated obstructive (≥50%) CAD. Separate core laboratories performed blinded adjudication of ACS and culprit lesions and quantification of baseline coronary CTA for percent diameter stenosis (%DS), percent cross-sectional plaque burden (PB), plaque volumes (PVs) by composition (calcified, fibrous, fibrofatty, and necrotic core), and presence of high-risk plaques (HRPs). RESULTS:We identified 234 ACS and control pairs (age 62 years, 63% male). More than 65% of patients with ACS had nonobstructive CAD at baseline, and 52% had HRP. The %DS, cross-sectional PB, fibrofatty and necrotic core volume, and HRP increased the adjusted hazard ratio (HR) of ACS (1.010 per %DS, 95% confidence interval [CI]: 1.005 to 1.015; 1.008 per percent cross-sectional PB, 95% CI: 1.003 to 1.013; 1.002 per mm3 fibrofatty plaque, 95% CI: 1.000 to 1.003; 1.593 per mm3 necrotic core, 95% CI: 1.219 to 2.082; all p < 0.05). Of the 129 culprit lesion precursors identified by coronary CTA, three-fourths exhibited <50% stenosis and 31.0% exhibited HRP. CONCLUSIONS:Although ACS increases with %DS, most precursors of ACS cases and culprit lesions are nonobstructive. Plaque evaluation, including HRP, PB, and plaque composition, identifies high-risk patients above and beyond stenosis severity and aggregate plaque burden.

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