Coronary Computed Tomography Angiography: Beyond Obstructive Coronary Artery Disease

Abstract

Nowadays, coronary computed tomography angiography (CCTA) has a role of paramount importance in the diagnostic algorithm of ischemic heart disease (IHD), both in stable coronary artery disease (CAD) and acute chest pain. Alongside the quantification of obstructive coronary artery disease, the recent technologic developments in CCTA provide additional relevant information that can be considered as “novel markers” for risk stratification in different settings, including ischemic heart disease, atrial fibrillation, and myocardial inflammation. These markers include: (i) epicardial adipose tissue (EAT), associated with plaque development and the occurrence of arrhythmias; (ii) late iodine enhancement (LIE), which allows the identification of myocardial fibrosis; and (iii) plaque characterization, which provides data about plaque vulnerability. In the precision medicine era, these emerging markers should be integrated into CCTA evaluation to allow for the bespoke interventional and pharmacological management of each patient.

Coronary Plaque in Athletes

“…The implications of plaque composition extend beyond mere anatomical characterization, as they have a significant prognostic role. While calcified coronary plaques are generally considered more stable and less prone to rupture, mixed and non-calcified ones exhibit greater vulnerability, and they are associated with an increased risk of cardiovascular events [34]. Therefore, the predominance of calcified plaques among athletes may confer a degree of protection against adverse cardiovascular outcomes, although further research is needed to confirm and elucidate the underlying mechanisms.…”

Cardiovascular Disease from Pathophysiology to Risk Estimation: Is Inflammation Estimated through Perivascular Attenuation on Computed Tomography the Key?

“…The appropriate selection of the diagnostic method should be tailored to the patient's characteristics, method availability, and the expertise of the local center [36][37][38][39][40]. Coronary CT is a valid and widely used method in daily clinical practice; it allows the evaluation of the presence of significant coronary stenoses as well as high-risk plaques characterized by positive remodeling, low Hounsfield units, napkin-ring sign, and the presence of intra-plaque spotty calcifications [41][42][43].…”

Computed tomography measured epicardial adipose tissue and psoas muscle attenuation: new biomarkers to predict major adverse cardiac events (MACE) and mortality in patients with heart disease and critically ill patients. Part I: Epicardial adipose tissue

“…Cardiac computed tomography (CCT) allows a clear depiction of the pericardium necessary for volumetric assessment of the EAT volume ( Figure 2 ). Compared to echocardiography and CMR, CCT has the best spatial resolution [ 75 ] and visibility [ 9 ] of the pericardium, allowing reliable (manual) contouring of the visceral pericardial layer. Subsequently, the CT filter selects the voxels within the visceral pericardium with a CT attenuation coefficient attributed to adipose tissue (range –190 Hounsfield Units [HU] to –30 HU for non-contrast-enhanced CCT) [ 9 , 75 ].…”

“…Compared to echocardiography and CMR, CCT has the best spatial resolution [ 75 ] and visibility [ 9 ] of the pericardium, allowing reliable (manual) contouring of the visceral pericardial layer. Subsequently, the CT filter selects the voxels within the visceral pericardium with a CT attenuation coefficient attributed to adipose tissue (range –190 Hounsfield Units [HU] to –30 HU for non-contrast-enhanced CCT) [ 9 , 75 ]. The total EAT volume is determined by summing all axial slices portraying EAT ( Figure 3 ).…”