Value of Multidetector CT Coronary Artery for diagnosis and risk factors of chronic total occlusion in patients with severe chest pain

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Value of Multidetector CT Coronary Artery for diagnosis and risk factors of chronic total occlusion in patients with severe chest pain

https://doi.org/10.21203/rs.3.rs-2489084/v1

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Background

Differentiating chronic total occlusion (CTO) from subtotal coronary occlusions (STOs) is often challenging to make from coronary angiography. Multidetector computerized tomography (MDCT) is essential in diagnosing and differentiating CTO from STO in symptomatic patients. The study is designed to explore the value of MDCT coronary angiography in discrimination between CTO and STO and assess the risk stratification in patients with severe chest pain.

Methods

This study is a descriptive cross-sectional one conducted from January 2021 to June 2022. A total of fifty patients (29 males, 21 females), ages ranging from (30–80 years), with coronary artery disease CAD) presented to the hospital with severe chest pain and were suspected of having arterial occlusion. They were examined using MDCT angiography.

Results

The prevalence of CAD was higher in males than females (58% vs. 42%). CAD was most prevalent in the age group of 51–60 (34%). Hypertension, DM, and smoking were the most common risk of CTO of coronary arteries. The CT findings of the coronary arteries showed that 27 cases (54%) were occluded entirely, while 23 (46%) were sub-totally occluded. It was shown that coronary artery calcification (CAC) was higher in patients with STO of coronary arteries compared to patients with CTO (26 cases subtotal vs. 20 cases total occlusion). The LAD was occluded in 30% of the patients and subtotal occluded in 20%, while the RCA was occluded in 14% and 18% subtotally occluded in the patients. The LCX was least frequent to occlusion. The Odd adjusted ratio (AOR) showed that diabetic patients had 1.68 increased Odds of having CTO of coronary arteries compared to non-diabetes (AOR = 1.68, 95% CI = .397–7.089), while hypertensive had 1.42 increased odds of having CTO compared to non-hypertensive (AOR = 1.42, 95% CI= (.366-5.474)). Smokers had 2.20 increased Odds of having CTO compared to non-smokers (AOR = 2.20, 95% CI = .461-10.532)

Conclusion

The study concluded that MDCT angiography is reliable and helps differentiate CTO from STO Hypertension, DM, and smoking are the most significant factors for CTO of coronary arteries. MDCT is recommended as a screening imaging tool for CAD symptomatic and asymptomatic populations.

Multidetector CT

Coronary Angiography

total occlusion

subtotal occlusion

In 2019, coronary artery disease (CAD) accounted for 182 million disability-adjusted life years and over 9.1 million deaths globally, making it the leading cause of disability and mortality. ^[1] According to a literature review on CAD risk factors, more than half of individuals in the Kingdom of Saudi Arabia (KSA) have hypercholesterolemia. About a quarter of all adults have hypertension and diabetes. ^[2–4]

In previous early studies, the amount of calcification, occlusion length, and identification of the artery course within a lengthy occluded segment were the most notable aspects seen in coronary CT angiography (CTA) to visualize CTOs ^{[5, 6]}. As opposed to standard CT, MDCT can cover a wide area of the body faster and in less time, making it a more advanced imaging method. Additionally, MDCT can evaluate the distribution and degree of calcification, which is the most critical predictor of CTO procedure success. ^[7–9]

CAD risk factors were classified as modifiable (hypertension, physical inactivity, hypercholesterolemia, diabetes mellitus, overweight, obesity, and smoking) and non-modifiable risk factors (family history, male sex, and age). According to a 2019 study, modifiable risk factors comprised only a small portion of predictive performance, with age, sex, and race accounting for 63–80%. However, significant drops in CAD occurrences were achieved by the control of modifiable risk variables. ^[10]

Coronary CTA may have difficulty distinguishing between high-grade stenosis and total occlusions due to its limited spatial resolution. Few studies utilized MDCT coronary angiography for CAD. There still needs to be more studies in diagnosing CAD with MDCT in KSA. Therefore, this study aims to determine coronary angiographic characteristics of patients who complain of severe chest pain in a major hospital in KSA.

Population and sampling of the study:

This study is a retrospective one conducted at the radiology department in King Salman Specialist Hospital, Hail, KSA, from January 2021 to June 2022. Fifty patients with CAD (29 men, 21 women), whose ages ranged from 39 to 65, arrived at the hospital complaining of chest pain and being suspected of having coronary arterial occlusion. They were examined using MDCT angiography by a machine (SOMATOM Definition, Siemens Medical Solution, Forchheim, Germany). The inclusion criteria included symptomatic patients who complained of severe chest pain. Exclusion criteria were: allergic to iodinated contrast material, renal insufficiency, severe respiratory function impairment, and heart failure. Asymptomatic patients were excluded from the study.

Methods

The patients were assessed using a 64-detector SOMATOM Definition high-resolution gated cardiac volume examination employing 0.625 mm slices of non-ionic contrast material (Xenetix) throughout a 5-second breath hold. For patients with heart rates greater than 70 beats per minute, axial two- and three-dimensional images were reconstructed using an advantage workstation (AWS) .Beta-blockers were used to lower heart rates before CT scans, and various post-processing techniques, such as maximum-intensity projection (MIP), curved multiplanar reconstruction (CPR), and volume rendering (VR), were used.

Coronary Artery Section And Evaluation Standard

As guidelines and the foundation for imaging evaluation, the American College of Cardiology (ACC) and American Heart Association (AHA) classification of coronary segments were adopted. The RCA is segmented into proximal, middle, and distal parts. ^[11] The left coronary artery is divided into a left main coronary artery (LM) and left circumflex branch (LCX), while the LAD branches into the proximal, middle, and distal segments. All coronary segments underwent gradual evaluation during segmentation. Even with a few artifacts, the examination was nevertheless able to satisfy the needs of the diagnostic. The vessel was not examined if any portion of the main coronary branch could not be analyzed.

Characterization Of Plaques And Ca Occlusion

According to the CT attenuation, coronary artery plaque was divided into the following three categories: Compared to the contrast-enhanced vessel lumen, calcified plaques are defined as having a high density, non-calcified plaques as having a lower density, and mixed plaques as having both calcified and non-calcified parts in a single plaque or within a coronary artery segment. The occlusion of the artery lumen was classified as STO and CTO as diagnosed by the MDCT. According to angiographic data, a coronary chronic complete occlusion (CTO) is 100% obstruction of a coronary artery for a period longer than or equivalent to three months. In contrast, STO was referred to as stenosis of greater than 99% with some flimsy anterograde blood flow. ^{[12, 13]}

The coronary artery calcium (CAC) was measured by chest computed tomography (CT) using the MDCT system. The amount of calcium was quantified using the CAC Data and Reporting System (CAC-DRS). The Calcium score was classified as mild, moderate, and severe according to the CAC Data and Reporting System (CAC-DRS), which is an innovative technique of reporting CAC that seeks to standardize the procedures for reporting results about CAC on all gated cardiac scans and non-gated chest CT scans. ^[14]

Data Collection

Experienced radiologists with years of MDCT coronary angiography scoring experience reviewed the MDCT angiograms in which the data were collected from the PACS system. A designed data collection was used to include the demographic data and clinical history of the patients who MDTC examined for CAD. The condition and course of the coronary arteries were determined using volume-generated and multiplanar reconstructions (MPR). Then, using curved MPR, the initial trans-axial slices were examined for any narrowing.

Statistical analysis

Data were analyzed and interpreted using SPSS version 25. categorical variables were summarized by calculating the number and percentage, whereas the mean and standard deviation were calculated for continuous variables. Binary logistic regression and 95% confidence intervals (95% CI) were applied to the data to examine the statistical significance of the association between CTO outcome and suspected risk factors.

Ethical approval

The ethical approval of scientific research of University of Hail approved the study and provided the ethically approved number (H- 022-126). The study participants' data were non-identities and were kept privately.

The demographic characteristics of the study sample showed that the prevalence of males was higher than females (58% vs. 42%). The prevalence of coronary artery disease was most prevalent in the age group of 51-60 years old (34%), as shown in Table 1. The MDCT images revealed CAC, stenosis, diffused presentation of CAD, and types of plaques, as presented in Figures (1, 2, and 3).

The risk factors are shown in figure 4. Hypertension and DM were the most common risk of CAD.

The CT findings of the coronary arteries showed that 27 cases (54%) were totally occluded, while 23 (46%) were sub-totally occluded (figure 5). The calcium score was shown to be higher in patients with total occlusion of coronary arteries than in patients with subtotal occlusion (26 and 20 total occlusions have moderate calcium scores), as shown in figure 6. Coronary artery calcification (CAC) was more prevalent in males than females (56.52% vs. 43.48%), as shown in figure 7.

The CT findings showed the LAD was occluded entirely in 30 % of the patients and subtotal occluded in 20%, while the RCA was occluded in 14% and 18% subtotally occluded in the patients. The LCX was totally occluded in only one case and subtotally occluded in16% of the patients (Table 2)

The risk factors which predict the total occlusion of coronary arteries are shown in Table 3. The adjusted Odd ratio (AOR) showed that diabetic patients had 1.68 increased Odds of having total occlusion of coronary arteries compared to males with non-diabetes (AOR= 1.68, 95% CI= .397–7.089), while hypertensive had 1.42 increased odds to have total occlusion compared to non-hypertensive (AOR =1.42, 95% CI= (.366-5.474)). Smokers had 2.20 increased Odds of having total occlusion of coronary arteries compared to non-smokers (AOR =2.20, 95% CI = .461-10.532)

Table 1. Demographic characteristics of the study sample

Variables	Frequency	Percent
Gender
Males	29	58.0
Females	21	42.0
Age groups
39-50 years	15	30.0
51-60 years	17	34.0
61-70 years	14	28.0

Table 2. MDCT coronary findings in patients with severe chest pain

Diagnosed Arteries	Total Occlusion		Subtotal Occlusion
Diagnosed Arteries	Frequency	Percent	Frequency	Percent
LAD	15	30.0	10	20.0
RCA	7	14.0	9	18.0
LCX	1	2.0	8	16.0
None	27	54.0	23	46.0
Total	50	100%	50	100%

Table 3. Factors predicting total occlusion of coronary arteries

Factors	Crude OR		Adjusted OR
Factors	Significance	COR (95% CI)	Significance	AOR (95% CI)
Age	0.807	101 (0.951-1.066)	0.779	1.01(.947-1.076
Gender
Males	0.845	0.89) .290-2.757	0.41	0.55(.135-2.241
Females	Ref	Ref	Ref	Ref
Diabetes Mellitus	0.879	1.10(.348-3.435)	0.482	1.68(.397-7.089)
Non-diabetes	Ref	Ref	Ref	Ref
Hypertensive	0.671	1.29 (0.404-4.094)	0.615	1.42(.366-5.474)
Non-hypertensive	Ref	Ref	Ref	Ref
Smokers	0.671	1.29(.404-4.094)	0.322	2.20 (.461-10.532)
Non-smokers	Ref	Ref	Ref	Ref

For many years, the preferred imaging method for assessing CA was conventional coronary angiography (CCA). In addition to being invasive, the limited number of 2D projection pictures obtained during catheterization and the lack of soft tissue information in CCA makes it less effective at detecting coronary artery defects. ^[15] MDCT angiography is the primary imaging method for identifying CA abnormalities. With MDCT, it is possible to detect CAD and the intricate anatomical relationships between adjacent structures quite well [^16,17].

In the present study, we evaluated the total and subtotal occlusion of the right coronary artery (RCA), left circumflex artery (LCX), and left anterior descending (LAD). It was shown that the prevalence of CAD was 46% in patients with severe chest pain undergoing MDCT coronary angiography. The incidence is slightly lower than that of Yousef et al, ^[18] and higher than the result of Yang et al. ^[19]. The study showed that the LCA was most affected than RCA. This finding agrees with the results of Yousef et al. ^[18]

The present study revealed that the LAD was totally occluded in 30% and subtotally occluded in 20% of patients with chest pain. It was reported that a blockage of the LAD artery has to be more than 70% to cause significant problems ^[20]. The study revealed that the RCA was totally occluded in 16% and subtotally occluded in 18%, while occlusion of the LCX is less frequent. Consistently data from the Dynamic Registry of the National Heart, Lung, and Blood Institute (1997-1999), CTO lesions are more prevalent in RCA and less prevalent in the LCX. ^[12]. Previous studies reported that LCX artery occlusions are estimated to account for 20% of myocardial infarctions (MIs) ^{[21, 22]}. LCX lesions are important because they are associated with an increased risk of heart failure and mortality at 90 days and one year compared to RCA and LAD lesions [23]. Epidemiologically, a quarter to a third of individuals with diagnostic coronary angiography has CTO lesions. However, the frequency in the general population is unknown because some individuals with CTO lesions are asymptomatic or hardly symptomatic and never receive definitive coronary angiography ^[12].

The current study showed that CA calcification was more prevalent in males than females and more deposited in subtotal occluded arteries than in total occluded ones. This finding is consistent with literature previous studies, which reported that Coronary artery calcification is quite frequent, affecting between 50 and 80 percent of males and 20 to 45 percent of women ^[24]; it is particularly prevalent in the older population, with one study stated that coronary artery calcification increases with age and is more prevalent in males than females .^[25] Current research suggests coronary calcification is an inflammatory response to atherosclerosis to stabilize coronary plaques ^[26]. However, the specific mechanism and effects of coronary calcification are still controversial. Thus, a myocardial infarction is often caused by unstable, poorly calcified plaques.

This study differs from other studies in that we studied the risk factors associated with CTO rather than general CAD. The study showed that smoking, hypertension, and diabetes mellitus were considered risk factors for coronary artery occlusion. Hypertension has long been considered a significant risk factor for cardiac disease due to the oxidative and mechanical stress that it causes on the artery wall. ^{[28, 29]} Previous studies reported that every third patient has hypertension, on average. In a 2009 research evaluating twelve modifiable risk variables, hypertension and smoking were the significant contributors to the greatest fatalities. ^[27]

On the other hand, DM is a primary cause of the major cause of CAD and heart failure. ^[30].Smoking is also considered a risk factor for occlusion of the coronary artery. According to one study, smoking was linked to occlusion in the LAD artery, although there was no relation between smoking and the occlusion site in the arteries. In five trials, smoking was associated with the severity of CAD. ^[31]

Generally, it is necessary to preselect patients with severe chest pain when employing MDCT as a noninvasive diagnostic method to evaluate advanced CAD to get accurate results. Therefore, the policy implications for MDCT examinations for CAD in the symptomatic population are significant.

Hypertension, DM, and smoking are the most significant factors for chronic total occlusion of coronary arteries. The LAD and RCA are the most coronary arteries vulnerable to total and subtotal occlusion in patients who complain of severe chest pain. We recommend that MDCT be used as a screening imaging tool for CAD, even in the asymptomatic population.

The following inherent limitations should be recognized before translating current esults to the other scenarios. The study is retrospective, and the results were derived from single-center datasets; these may cause some missing data related to CAD and clinical history. The sample size needs to be bigger; this may affect the significance of regression analysis, thus causing some results to be insignificant, although the findings are clinically significant.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The study followed the principles of the Declaration of Helsinki and was approved by the Ethics Committee of the Affiliated University of Hail and Hail cluster health approved the study, protocol and provided the ethically approved number (H- 022-126). all methods were carried out in accordance with relevant guidelines and regulations. The informed consent was obtained from all subjects and/or their legal guardian(s).

• Consent for publication

Not applicable

• Competing interests

The authors declare that they have no competing interests

• Funding

This research received no external funding

• Authors' contributions

Conceptualization: QTA and MTA; methodology: MY; validation: EY; formal analysis AA; writing original draft preparation: MS; writing, review and editing: BA and MG. All authors read and approved the final manuscript

• Acknowledgements

We thank the Radiology Department in King Salman Specialist Hospital, Hail, KSA for their help in data collection

• Authors’ Information

Qurain Turki Alshammari* , PhD, Afnan Almalahi, Msc, Bushra Abdelmalik, MD PhD, Elgeili Yousif1, PhD, Meshari T Alshammari, PhD, ,Mohammed Salih, PhD.

Diagnostic Radiology Department, College of Applied Medical Sciences, University of Hail, Hail, Saudi Arabia.

Mohamed Yousef , PhD

Radiological Sciences Program, Batterjee Medical College, Jeddah, Saudi Arabia.

Moawia Gameraddin, PhD

Department of Diagnostic Radiologic Technology, Faculty of Applied Medical Sciences, Taibah University, Al‑Madinah, Saudi Arabia

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No competing interests reported.

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Value of Multidetector CT Coronary Artery for diagnosis and risk factors of chronic total occlusion in patients with severe chest pain

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Materials And Method

Population and sampling of the study:

Methods

Coronary Artery Section And Evaluation Standard

Characterization Of Plaques And Ca Occlusion

Data Collection

Statistical analysis

Results

Discussion

Conclusion

Study Limitation

Declarations

References

Additional Declarations

Status:

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