High-Risk Coronary Plaque on Computed Tomography Angiography: Time to Recognize a New Imaging Risk Factor.
High-Risk Coronary Plaque on Computed Tomography Angiography: Time to Recognize a New Imaging Risk Factor.
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计算机断层扫描血管造影中的高风险冠状动脉斑块：是时候识别新的成像风险因素了。
DOI：
10.1161/circimaging.117.007288
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发表时间：
2018
期刊：
影响因子：
--
通讯作者：
Hoffmann,Udo
中科院分区：
文献类型：
--
作者：
Ferencik,Maros;Hoffmann,Udo
2 CT上的Ferencik和Hoffmann高危斑块：一种新的影像学危险因素显著的阻塞性CAD与MACE密切相关，高危斑块的增量预后价值在非阻塞性CAD患者中将最为突出。9为了讨论修改药物治疗的潜力，从一级预防中既定治疗阈值的角度来看待高危斑块患者发生主要不良事件的可能性是有帮助的。例如，Motoyama等人13报告了4年随访中无CAD的MACE发生率为0.6%，无高危斑块的非阻塞性CAD为1.2%，有高危斑块且无狭窄的患者为14.9%。因此，10年事件风险将高于7.5%，即使没有阻塞性CAD，也是高危斑块患者开始降脂治疗的公认阈值。然而，高危斑块的发现并不包括在目前的二级预防降脂和抗血小板治疗指南中。14对于临床动脉粥样硬化性心血管疾病（定义为心肌梗死、稳定型或不稳定型心绞痛、冠状动脉或其他动脉血运重建、卒中、短暂性脑缺血发作或推测为动脉粥样硬化起源的外周动脉疾病病史）患者，建议进行二级预防。仅仅存在冠状动脉粥样硬化斑块不包括在需要二级预防的诊断列表中。一级预防指南仅建议使用冠状动脉钙≥ 300作为指导开始使用他汀类药物决定的额外因素。14然而，对于如何根据冠状动脉CTA上CAD的存在和程度来修改降脂治疗的适应症，尚无明确的指南。然而，已有数据表明，将CAD的存在和程度信息纳入动脉粥样硬化性心血管疾病计算器的汇总队列方程中，可显著改善非梗阻性CAD中他汀类药物治疗的充分分配。15，16显然，这些数据强调，缺乏指导非梗阻性CAD患者使用预防性最佳药物治疗的指南仍然是一个错失的机会。治疗的不确定性反映在非梗阻性CAD患者使用最佳药物治疗的巨大差异中。只有47%的非梗阻性CAD患者通过有创冠状动脉造影术检测在1年内接受了最佳药物治疗。[17]重要的是，各医院的最佳药物治疗存在2倍的差异。正如SCOT-HEART试验（苏格兰心脏试验计算机断层扫描）分析所示，预防性治疗（阿司匹林使用增加12倍，他汀类药物使用增加3.5倍）的增加，主要是在非梗阻性CAD患者中，导致致死性和非致死性心肌梗死减少50%。18与任何斑块的存在相比，高危斑块与MACE的关联更强，是否在指导预防性治疗的修改方面也有价值尚不清楚。来自纵向研究的数据显示，强化他汀类药物治疗可通过增加致密钙化斑块的体积来改变斑块进展并改变斑块特征，从而可能导致斑块稳定并降低高危斑块特征。19然而，随机临床试验的结果清楚地表明预防性治疗对高危斑块患者的益处是缺失的。临床试验和成像研究人员的社区应该.
2 Ferencik and Hoffmann High-Risk Plaque on CT: a New Imaging Risk Factor the strong association of significant obstructive CAD with MACE, the incremental prognostic value of high-risk plaque will be most prominent in patients with nonobstructive CAD. 9 To discuss the potential to modify medical therapy, it is helpful to put the probability of MACE in patients with highrisk plaque in the perspective of established treatment thresholds in primary prevention. As an example, Motoyama et al13 reported MACE rates of 0.6% in the absence of CAD, 1.2% for nonobstructive CAD without high-risk plaque, and 14.9% in patients with high-risk plaque and no stenosis for 4 years of follow-up. Thus, 10-year risk of events would be above 7.5%, an accepted threshold for the initiation of lipid-lowering therapies in patients with high-risk plaque even in the absence of obstructive CAD. However, the finding of high-risk plaque is not included in the current guidelines for lipid-lowering and antiplatelet treatment in secondary prevention. 14 The secondary prevention is recommended for patients with clinical atherosclerotic cardiovascular disease (defined as history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease presumed to be of atherosclerotic origin). The mere presence of coronary atherosclerotic plaque is not included in the list of diagnoses requiring secondary prevention. The primary prevention guidelines only recommend the use of coronary artery calcium≥ 300 as an additional factor guiding decision about the initiation of statin. 14 However, there are no clear guidelines for how indication of lipid-lowering therapies may be revised based on the presence and extent of CAD on coronary CTA. Nevertheless, there are already data demonstrating that incorporation of information on the presence and extent of CAD into the pooled cohort equation of the Atherosclerotic Cardiovascular Disease calculator significantly improves adequate allocation of statin therapy in nonobstructive CAD. 15, 16 Clearly, these data emphasize that the lack of guidelines directing the use of the preventative optimal medical therapy in patients with nonobstructive CAD remains a missed opportunity. Therapeutic uncertainty is reflected in large variations in the use of optimal medical therapies in patients with nonobstructive CAD. Only 47% of patients with nonobstructive CAD detected by invasive coronary angiography were receiving optimal medical therapy within 1 year. 17 Importantly, there was 2-fold variation in optimal medical therapy across hospitals. As it was shown in an analysis of the SCOT-HEART trial (Scottish Computed Tomography of the HEART Trial), the increase in preventative therapies (12-fold increase in aspirin use and 3.5-fold increase in statin use), predominantly in patients with nonobstructive CAD, resulted in 50% reduction in fatal and nonfatal myocardial infarctions. 18 Whether high-risk plaque, which has even stronger association with MACE as compared with the presence of any plaque, has also value in guiding the modification of preventative treatments is unknown. Data from longitudinal studies showed that intensive statin treatment could change the plaque progression and change plaque characteristics by increasing the volume of dense calcified plaque, potentially leading to plaque stabilization and decreasing high-risk plaque characteristics. 19 However, results from randomized clinical trials clearly demonstrating the benefit of preventative treatments in patients with high-risk plaque are missing. The community of clinical trials and imaging researchers should …
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影响因子：
5.3
作者：
Auscher, Soren;Heinsen, Laurits;Egstrup, Kenneth
通讯作者：
Egstrup, Kenneth
影响因子：
24
作者：
Williams MC;Hunter A;Shah ASV;Assi V;Lewis S;Smith J;Berry C;Boon NA;Clark E;Flather M;Forbes J;McLean S;Roditi G;van Beek EJR;Timmis AD;Newby DE;SCOT-HEART Investigators
通讯作者：
SCOT-HEART Investigators
影响因子：
24
作者：
Puchner, Stefan B.;Liu, Ting;Mayrhofer, Thomas;Truong, Quynh A.;Lee, Hang;Fleg, Jerome L.;Nagurney, John T.;Udelson, James E.;Hoffmann, Udo;Ferencik, Maros
通讯作者：
Ferencik, Maros
影响因子：
5.4
作者：
Oxner A;Elbaz-Greener G;Qui F;Masih S;Zivkovic N;Alnasser S;Cheema AN;Wijeysundera HC
通讯作者：
Wijeysundera HC