Coronary artery disease is asymptomatic in most of the population. When severe enough it can cause angina or an acute coronary syndrome including myocardial infarction. CAD may also present with heart failure or sudden cardiac death.
Coronary artery disease is primarily due to atherosclerosis, an inflammatory process that leads to atheroma development and remodeling/stenosis of the coronary arteries. A stenosis of >50% of diameter or >75% cross-section diameter reduction can lead to angina. Thrombus formation after plaque disruption can lead to acute coronary syndrome 1,2.
- non-modifiable: family history, age, male sex 1
- modifiable: hypercholesterolemia, left ventricular hypertrophy, obesity, hypertension, diabetes, sedentary lifestyle, smoking, alcohol 1
There are a variety of techniques to image coronary artery disease including both anatomical and functional modalities. Coronary angiography has been the mainstay for many years, but in certain patient groups is being replaced by non-invasive imaging such as coronary CT angiography (cCTA).
There are several appropriate clinical indications for the performance of coronary CTA 8:
- acute chest pain in patients with a low-to-intermediate pretest probability of coronary artery disease
- evaluation of coronary artery anatomy and bypass grafts
- assessment of congenital heart disease
- coronary artery calcium scoring
- patients with technically limited images from echocardiography or MRI
Haemodynamically-significant stenoses are those >70% for all coronary arteries, except the left main coronary artery where >50% stenosis is considered significant 7.
In a post-hoc analysis of prospective acquired data, a cutoff value > -70 HU of the perivascular fat attenuation index (FAI) around the proximal right coronary artery was found to be predictive of increased all-cause mortality 10.
The recently proposed SCCT grading scale for stenosis severity assesses the degree of luminal diameter stenosis 6:
- 0% = no visible stenosis
- 1-24% = minimal stenosis
- 25-49% = mild stenosis
- 50-69% = moderate stenosis
- 70-99% = severe stenosis
- 100% = occlusion
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- 6. Sayols-Baixeras S, Lluís-Ganella C, Lucas G et-al. Pathogenesis of coronary artery disease: focus on genetic risk factors and identification of genetic variants. Appl Clin Genet. 2014;7: 15-32. doi:10.2147/TACG.S35301 - Free text at pubmed - Pubmed citation
- 7. Abbara S, Miller SW. Cardiac Imaging: The Requisites. Mosby. ISBN:0323055273. Read it at Google Books - Find it at Amazon
- 8. Schroeder S, Achenbach S, Bengel F, Burgstahler C, Cademartiri F, de Feyter P, George R, Kaufmann P, Kopp AF, Knuuti J, Ropers D, Schuijf J, Tops LF, Bax JJ; Working Group Nuclear Cardiology and Cardiac CT; European Society of Cardiology; European Council of Nuclear Cardiology. Cardiac computed tomography: indications, applications, limitations, and training requirements: report of a Writing Group deployed by the Working Group Nuclear Cardiology and Cardiac CT of the European Society of Cardiology and the European Council of Nuclear Cardiology. Eur Heart J. 2008 Feb;29(4):531-56. Epub 2007 Dec 15. DOI: 10.1093/eurheartj/ehm544
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- 10. Oikonomou EK, Marwan M, Desai MY, Mancio J, Alashi A, Hutt Centeno E, Thomas S, Herdman L, Kotanidis CP, Thomas KE, Griffin BP, Flamm SD, Antonopoulos AS, Shirodaria C, Sabharwal N, Deanfield J, Neubauer S, Hopewell JC, Channon KM, Achenbach S, Antoniades C. Non-invasive detection of coronary inflammation using computed tomography and prediction of residual cardiovascular risk (the CRISP CT study): a post-hoc analysis of prospective outcome data. (2018) Lancet (London, England). 392 (10151): 929-939. doi:10.1016/S0140-6736(18)31114-0 - Pubmed