,_/A. - Comparison of the RelationBetween the Calcium Score and Plaque Ch'aracteristics in PatientsWith Acute Coronary SyndromeVersus Patients With StableCoronaryArtery Disease, Assessed by Computed Tomography Angiography and Virtual Histology lntravascular Ultrasound Jo€lla E. van Velzen,MDU'''*, Fleur R. de Graaf', MD". J. Wouter Jukema, MD, PhDo'', GreetjeJ. de Grooth, MD, PhD", Gabija Pundziute, MD, PhD". Lucia J. Kroft, MD. PhDb, Albert de Roos,MD, PhDb. JohanH. C. Reiber, PhDb, Jeroen J. Bax, MD. PhDo, i- Martin J. Schalij,MD. PhD",Joanne D. Schui.if. PhDu, and Ernst E. van der Wall, MD, PhDo A considerable number of patients with an acute coronary syndrome (ACS) who present with a 0 or low calcium score (CS) still demonstrate coronaryartery disease (CAD) and significant stenosis. The aim of the present study was to evaluate the relationbetween the CS and the degree and character of atherosclerosis in patients with suspected ACS versus patients with stable CAD obtained by computed tomography angiography and virtual histology intravascu- lar ultrasound (VH IVUS).Overall 112 patients were studied, 53with ACS and 59 with stable CAD. Calciunr scoring and computed tonrography angiography wereperformed and followed by VH IVUS. On computed tomography angiography each segment wasevaluated for plaque and classified as noncalcified, mixed, or calcified. Vulnerable plaque characteristics on VH IVUS were defined by percent necrotic core and presence of thin-cap fibroatheroma. lf the CS was 0, patients with ACS had a higher mean numberof plaques (5.0 + 2.0 vs 2.0 + 1.9, p <0.05) and noncalcified plaques (4.6 + 3.5vs 1.3= 1.9, p <0.05) on computed tomography angiography than those with stable CAD. lf the CS was 0, VH IVUS demonstrated that patients with ACS had a larger amount of necrotic core area (0.58 r- 0.73 vs 0.22t 0.43 mm2, p <0.05)and a higher nreannumberof thin-capfibroatheromas (0.6 + 0.7 vs 0.1 -+ 0.3, p <0.05)than patients with stable CAD. In conclusion, even in the presence of a 0 CS, patients with ACShave increased plaque burden and increased vulnerability compared to patients with stab{e CAD. Therefore, absence of coronarycalcification doesnot exclude the presence of clinically relevant and potentiallyvulnerable atherosclerotic plaque burden in patients with ACS. O 20ll Elsevier Inc. All rights reserved. (Am J Cardiol 201l;108:658-664) Departments of "Cardiology and oRacliology. Leiden UniversityMed- ical Center. Leiden. The Netherlands: 'lnteruniversity Cardiology lnstitute of the Netherlands, Utrecht. The Netherlands. Manuscript received Febru- ary 22,2011; revised nranuscript received and accepted April 3,2011. This work was supported by Grant 20078223 fronr the Dutch Heart Foundation. The Hague.The Netherlands to Dr. van Velzen; the Dutch Technology Foundation STW, Utrecht,The Netherlands; and Grant 10084 from Applied Science Division I and the Technology Program of the Ministry of Economic Affairs, The Hague, The Netherlands to Dr. de Graaf.Dr. Jukema receives grant.s from Bicltronik. Berlin. Germany; Bos- ton Scientihc, Natick: Astra 7,eneca,, London, United Kingdom: Pfizer, New York: MSD. New Jersey. Dr. Schalijhasresearch grants from Biotro- nik, Berlin, Germany: Boston Scicntilic, Natick. Massachusctts: and Medtronic, Minneapolis. Minnesota.Dr. Bax has research grants fronr Biotronik;BMS Medical Imaging, North Billerica.Massachusetts: Boston Scientific: Edwards Lifesciences, lrvine, California: CE Healthcare. Buck- inghamshire. UnitedKingdonr; Medtronic: and St. JudeMedical, St. Paul, Minnesota. *Corresponding author: Tel: 3l -7l-526-1757; fax: 3l-7l-526-6809. E-nnil addre.ss: j.e.r'[email protected] (J.E. van Velzen). 0002-9l49lll/$ - see front matter O 20ll Elsevier tnc. All rightsreserved. doi: l 0. | 0 | 6/j.amjcard.20 | | .04.009 The prognostic value of the coronary calciurn score (CS) has been extensivelyinvestigittect, and very low rates ol' cardiac events have beendemonstrated in patients with a 0 CS.r-4 However, preliminary data in patients presenting with acute coronary syndrome (ACS) suggest a largercon- tribution of noncalcified plaque to overall plaqueburden compared to patients with stable coronary artery disease (CAD).5'6 As a consequence, a 0 or low CS may signifi- cantly_ underestimate overall plaque burden in the setting of ACS.7 However,currentdata on how clinical presentation affects the relation betweenCS and coronary plaquechar- acteristics are still scarce. An important advantage of com- puted tomography angiography (CTA) over the CS is that additional information on stenosis severity and plaque com- position can be obtained.s'e Invasively, virtual histology intravascular ultrasound (VH IVUS) offers detailed infor- mationon coronary plaquecharacteristics. ro-t2 The aim of the present study was to comparethe relation between the CS and plaquecharacteristics in patients with ACS versus patients with stable CAD assessed noninvasively by CTA and invasively by VH IVUS. 3 www.ajconline.org
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,_/A.- Comparison of the Relation Between the Calcium Score and PlaqueCh'aracteristics in Patients With Acute Coronary Syndrome Versus
Patients With Stable Coronary Artery Disease, Assessed byComputed Tomography Angiography and Virtual Histology
lntravascular Ultrasound
Jo€lla E. van Velzen, MDU'''*, Fleur R. de Graaf', MD". J. Wouter Jukema, MD, PhDo'',Greetje J. de Grooth, MD, PhD", Gabija Pundziute, MD, PhD". Lucia J. Kroft, MD. PhDb,
Albert de Roos, MD, PhDb. Johan H. C. Reiber, PhDb, Jeroen J. Bax, MD. PhDo, i-
Martin J. Schalij, MD. PhD", Joanne D. Schui.if. PhDu, and Ernst E. van der Wall, MD, PhDo
A considerable number of patients with an acute coronary syndrome (ACS) who present witha 0 or low calcium score (CS) still demonstrate coronary artery disease (CAD) and significantstenosis. The aim of the present study was to evaluate the relation between the CS and thedegree and character of atherosclerosis in patients with suspected ACS versus patients withstable CAD obtained by computed tomography angiography and virtual histology intravascu-lar ultrasound (VH IVUS). Overall 112 patients were studied, 53 with ACS and 59 with stableCAD. Calciunr scoring and computed tonrography angiography were performed and followedby VH IVUS. On computed tomography angiography each segment was evaluated for plaqueand classified as noncalcified, mixed, or calcified. Vulnerable plaque characteristics on VHIVUS were defined by percent necrotic core and presence of thin-cap fibroatheroma. lf the CSwas 0, patients with ACS had a higher mean number of plaques (5.0 + 2.0 vs 2.0 + 1.9,p <0.05) and noncalcified plaques (4.6 + 3.5 vs 1.3 = 1.9, p <0.05) on computed tomographyangiography than those with stable CAD. lf the CS was 0, VH IVUS demonstrated thatpatients with ACS had a larger amount of necrotic core area (0.58 r- 0.73 vs 0.22 t 0.43 mm2,p <0.05) and a higher nrean number of thin-cap fibroatheromas (0.6 + 0.7 vs 0.1 -+ 0.3, p<0.05) than patients with stable CAD. In conclusion, even in the presence of a 0 CS, patientswith ACS have increased plaque burden and increased vulnerability compared to patients withstab{e CAD. Therefore, absence of coronary calcification does not exclude the presence ofclinically relevant and potentially vulnerable atherosclerotic plaque burden in patients withACS. O 20ll Elsevier Inc. All rights reserved. (Am J Cardiol 201l;108:658-664)
Departments of "Cardiology and oRacliology. Leiden University Med-ical Center. Leiden. The Nether lands: ' lnteruniversi ty Cardiology lnst i tuteof the Netherlands, Utrecht. The Netherlands. Manuscript received Febru-ary 22,2011; revised nranuscr ipt received and accepted Apr i l 3,2011.
This work was supported by Grant 20078223 fronr the Dutch HeartFoundation. The Hague. The Netherlands to Dr. van Velzen; the DutchTechnology Foundation STW, Utrecht, The Netherlands; and Grant 10084from Applied Science Division I and the Technology Program of theMinistry of Economic Affairs, The Hague, The Netherlands to Dr. deGraaf. Dr. Jukema receives grant.s from Bicltronik. Berl in. Germany; Bos-ton Scientihc, Natick: Astra 7,eneca,, London, United Kingdom: Pfizer,New York: MSD. New Jersey. Dr. Schali j has research grants from Biotro-nik, Ber l in, Germany: Boston Scicnt i l ic , Nat ick. Massachusctts: andMedtronic, Minneapolis. Minnesota. Dr. Bax has research grants fronrBiotronik; BMS Medical Imaging, North Bil lerica. Massachusetts: BostonScientific: Edwards Lifesciences, lrvine, California: CE Healthcare. Buck-inghamshire. Uni ted Kingdonr; Medtronic: and St. Jude Medical , St . Paul ,Minnesota.
*Corresponding author: Tel : 3 l -7 l -526-1757; fax: 3 l -7 l -526-6809.E-nni l addre.ss: j .e.r '[email protected] l (J.E. van Velzen).
0002-9l49l l l /$ - see front matter O 20l l Elsevier tnc. Al l r ights reserved.doi: l 0. | 0 | 6/j .amjcard.20 | | .04.009
The prognostic value of the coronary calciurn score (CS)has been extensively in vestigittect, and very low rates ol'cardiac events have been demonstrated in patients with a 0CS.r-4 However, preliminary data in patients presentingwith acute coronary syndrome (ACS) suggest a larger con-tribution of noncalcif ied plaque to overall plaque burdencompared to patients with stable coronary artery disease(CAD).5'6 As a consequence, a 0 or low CS may signifi-cantly_ underestimate overall plaque burden in the setting ofACS.7 However, current data on how clinical presentationaffects the relation between CS and coronary plaque char-acteristics are still scarce. An important advantage of com-puted tomography angiography (CTA) over the CS is thatadditional information on stenosis severity and plaque com-position can be obtained.s'e Invasively, virtual histologyintravascular ultrasound (VH IVUS) offers detailed infor-mation on coronary plaque characteristics. ro-t2 The aim ofthe present study was to compare the relation between theCS and plaque characteristics in patients with ACS versuspatients with stable CAD assessed noninvasively by CTAand invasively by VH IVUS.
3
www.ajconline.org
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