Brendel J M, Nikolaou K, Foldyna B
Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland.
Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
Radiologie (Heidelb). 2024 Dec;64(12):946-955. doi: 10.1007/s00117-024-01385-y. Epub 2024 Nov 12.
CLINICAL/METHODICAL ISSUE: Risk assessment and accurate plaque characterization are key to individual prognosis in coronary artery disease (CAD).
The standard of care is cardiac computed tomography (CT), including calcium scoring and coronary CT angiography (CCTA). Diagnosis is based on the CAD-RADS (Coronary Artery Disease-Reporting and Data System) classification.
New developments include CT-based fractional flow reserve (CT-FFR) and plaque quantification ("virtual histology").
A calcium score of 0 indicates an event risk of less than 1% over 10 years [7, 17]. CAD-RADS classes 1 to 5 allow risk assessment compared to patients without coronary plaques [2]. CT-FFR has high accuracy (area under the curve [AUC] 0.90; 95% confidence interval 0.87-0.94) in assessing the hemodynamic significance of stenoses compared with invasive coronary angiography [25]. Plaque quantification has shown that a necrotic core greater than 4% is associated with an almost fivefold increase in 5‑year event risk [29].
The presence of obstructive CAD (stenosis > 50%) is a strong prognostic factor. The evaluation of the hemodynamic relevance of 40-90% stenoses by CT-FFR or other functional tests is already guideline-compliant in the USA, but not yet in Germany. Quantitative approaches to measure plaque volume and composition are gaining importance in research and are expected to become relevant in clinical practice.
The CAD-RADS 2.0 classification, which also provides therapy recommendations, should be used to assess the extent of CAD.
临床/方法学问题：风险评估和准确的斑块特征描述是冠状动脉疾病（CAD）个体预后的关键。
标准治疗方法是心脏计算机断层扫描（CT），包括钙化积分和冠状动脉CT血管造影（CCTA）。诊断基于CAD-RADS（冠状动脉疾病报告和数据系统）分类。
新进展包括基于CT的血流储备分数（CT-FFR）和斑块定量分析（“虚拟组织学”）。
钙化积分为0表明10年内事件风险低于1%[7,17]。与无冠状动脉斑块的患者相比，CAD-RADS 1至5类可进行风险评估[2]。与有创冠状动脉造影相比，CT-FFR在评估狭窄的血流动力学意义方面具有较高的准确性（曲线下面积[AUC]为0.90；95%置信区间为0.87-0.94）[25]。斑块定量分析表明，坏死核心大于4%与5年事件风险几乎增加五倍相关[29]。
存在阻塞性CAD（狭窄>50%）是一个强有力的预后因素。在美国，通过CT-FFR或其他功能测试评估40%-90%狭窄的血流动力学相关性已符合指南要求，但在德国尚未符合。测量斑块体积和成分的定量方法在研究中越来越重要，预计将在临床实践中发挥作用。
应使用CAD-RADS 2.0分类（该分类也提供治疗建议）来评估CAD的程度。
