Assessment of Coronary Inflammatory Risk From Noncontrast Cardiac Computed Tomography.
Authors
Affiliations (30)
Affiliations (30)
- Acute Multidisciplinary Imaging and Interventional Centre, British Heart Foundation Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.
- National Institute for Health and Care Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom.
- Cardiology and Angiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Caristo Diagnostics Ltd, Oxford, United Kingdom.
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
- Royal Brompton and Harefield Hospitals, London, United Kingdom.
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom.
- Department of Cardiology, Guys and St Thomas' Hospital, London, United Kingdom.
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester, Leicester, United Kingdom.
- Leicester British Heart Foundation Centre of Research Excellence, Leicester, United Kingdom.
- Leicester NIHR Biomedical Research Centre, Leicester, United Kingdom.
- Royal United Hospitals Bath NHS Foundation Trust, Bath, United Kingdom.
- Royal Papworth Hospital, Cambridge, United Kingdom.
- Department of Cardiology, Translational Cardiovascular Research Group, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, United Kingdom.
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom.
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.
- Department of Cardiology, Sandwell and West Birmingham NHS Trust, Birmingham, United Kingdom.
- Cardiovascular Science, University of Birmingham, Birmingham, United Kingdom.
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundations Trust, Newcastle upon Tyne, United Kingdom.
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom.
- Heart and Vascular Institute and Center for Inflammation Imaging, Mass General Brigham and Harvard Medical School, Boston, Massachusetts.
- Division of Cardiology, Department of Medicine University of Texas Southwestern, Dallas.
- Department of Dermatology, UT Southwestern Medical Center, Dallas, Texas.
- The George Washington University School of Medicine and Health Sciences, Washington, DC.
- Cleveland Clinic Heart and Vascular Institute, Cleveland, Ohio.
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.
- Department of Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany.
- Institute of Cardiovascular Science, University College London, London, United Kingdom.
Abstract
Individuals with low or minimal coronary artery calcification (CAC) are considered at low cardiovascular risk, but a substantial absolute number of cardiovascular events occur in this population; assessment of coronary inflammation using the fat attenuation index (FAI) score may identify residual inflammatory risk beyond CAC score. To assess whether coronary inflammation measured on coronary computed tomography angiography (CCTA) or noncontrast cardiac CT (NCCT) identifies individuals at high cardiovascular risk independent of CAC burden. In this cohort study, a novel artificial intelligence algorithm for measuring FAI score on NCCT was trained and tested in an independent, multicenter, longitudinal cohort of consecutive individuals undergoing clinically indicated CCTA and NCCT for CAC score between 2010 and 2021, with median (IQR) follow-up of 6.7 (4.6-10.0) years. Data were analyzed from January 2010 to March 2024. Agatston CAC score and coronary inflammation from both CCTA (CCTA FAI score, established biomarker) and NCCT (NC FAI score, novel biomarker). The primary outcome was cardiovascular (CV) mortality; the secondary outcome was major adverse cardiovascular events (MACE), comprising myocardial infarction, new-onset heart failure, or CV death. The derivation cohort included 6818 individuals (median [IQR] age, 61 [51-71] years; 3543 female participants [52.0%]), and the external validation clinical outcomes cohort included 19 110 individuals (median [IQR] age, 56.0 [48.0-64.0] years; 9289 female participants [48.6%]). During follow-up, 536 CV deaths and 1727 MACE occurred. FAI scores independently stratified CV mortality risk across CAC score categories, with the strongest associations among individuals with CAC score of 0. Adding CCTA FAI score or NC FAI score to CAC score significantly improved risk discrimination (area under the curve increased from 0.76 to 0.81 and 0.80, respectively; P < .001), reclassification (net reclassification index), and net benefit across all risk thresholds. Among 89 CV deaths in individuals with CAC score of 0 and 138 CV deaths with CAC score of 1 through 99, 44.9% and 44.2% had NC FAI score above the 75th percentile, respectively. Among individuals with CAC score of 0, CV mortality rates increased from 1.4 to 4.0 per 1000 person-years for those with NC FAI score above the 75th percentile, and MACE rates increased from 5.9 to 13.3 per 1000 person-years. Per the results of this cohort study, NC FAI score provides prognostic performance comparable to CCTA FAI score and improves cardiovascular risk prediction and reclassification beyond CAC score. Elevated FAI score, derived from either CCTA or NCCT, should be interpreted as a risk-enhancing factor that may prompt intensification of established, evidence-based preventive measures and may serve as a potential future gatekeeper for the use of targeted anti-inflammatory treatments.