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Comprehensive plaque assessment by coronary CT angiography

Nature Reviews Cardiology volume 11, pages 390–402 (2014)Cite this article

Subjects

Key Points

  • Most acute coronary events result from sudden luminal thrombosis due to rupture of an atherosclerotic plaque

  • Modern computed tomography (CT) scanners enable robust coronary plaque characterization and quantification

  • Large plaque volume, low CT attenuation, napkin-ring sign, positive remodelling, and spotty calcification are all associated with plaques vulnerable to rupture

  • Computational fluid dynamic simulation enables plaque-specific endothelial shear stress and fractional flow reserve assessment, and thus permits functional characterization of plaques

  • Coupling individual plaque morphology with plaque-specific functional data will enable new noninvasive detection of vulnerable plaques with CT

Abstract

Most acute coronary syndromes are caused by sudden luminal thrombosis due to atherosclerotic plaque rupture or erosion. Preventing such an event seems to be the only effective strategy to reduce mortality and morbidity of coronary heart disease. Coronary lesions prone to rupture have a distinct morphology compared with stable plaques, and provide a unique opportunity for noninvasive imaging to identify vulnerable plaques before they lead to clinical events. The submillimeter spatial resolution and excellent image quality of modern computed tomography (CT) scanners allow coronary atherosclerotic lesions to be detected, characterized, and quantified. Large plaque volume, low CT attenuation, napkin-ring sign, positive remodelling, and spotty calcification are all associated with a high risk of acute cardiovascular events in patients. Computation fluid dynamics allow the calculation of lesion-specific endothelial shear stress and fractional flow reserve, which add functional information to plaque assessment using CT. The combination of morphologic and functional characteristics of coronary plaques might enable noninvasive detection of vulnerable plaques in the future.

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Figure 1: The morphology and functional characteristics of stable and vulnerable plaques.
Figure 2: Example of plaque characterization and quantification using a dedicated automated software tool and CCTA data set.
Figure 3: Cross-sectional CT showing coronary plaque with napkin-ring sign and spotty calcification.
Figure 4: Traditional and attenuation pattern-based plaque classification schemes in CCTA.
Figure 5: Time averaged ESS map of a left coronary artery derived by computation fluid dynamics simulation.
Figure 6: In histopathological studies of patients who suffered sudden cardiac death, 40% of nonruptured TCFAs also caused >75% luminal narrowing.
Figure 7: FFR-CT compared with CCTA and coronary angiogram for the identification of significant stenoses.
Figure 8: An illustration of potential comprehensive plaque assessment with CCTA.

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Acknowledgements

P.M-H. acknowledges support from the European Union, State of Hungary, and European Social Fund in the framework of TÁMOP 4.2.4. A/1-11-1-2012-0001 'National Excellence Program'. M.F. acknowledges support from the American Heart Association (grant number: 13FTF16450001).

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Authors and Affiliations

  1. MTA-SE Lendület Cardiovascular Imaging Research Group, Heart and Vascular Centre, Semmelweis University, 68 Varosmajor ut, Budapest, 1025, Hungary

    Pál Maurovich-Horvat & Béla Merkely

  2. Division of Cardiology and Department of Radiology, Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, 02114, MA, USA

    Maros Ferencik & Udo Hoffmann

  3. Stony Brook University, 101 Nicolls Road, Stony Brook, 11794, NY, USA

    Szilard Voros

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  1. Pál Maurovich-Horvat
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  2. Maros Ferencik
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  4. Béla Merkely
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  5. Udo Hoffmann
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The authors contributed equally to researching data for the article, discussion of content, writing, reviewing, and editing of the manuscript before submission.

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Correspondence to Udo Hoffmann.

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Supplementary Table 1

Morphologic computed tomography features of vulnerable plaques (DOCX 38 kb)

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Maurovich-Horvat, P., Ferencik, M., Voros, S. et al. Comprehensive plaque assessment by coronary CT angiography. Nat Rev Cardiol 11, 390–402 (2014). https://doi.org/10.1038/nrcardio.2014.60

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