Acute coronary syndrome risk in coronary side branch versus main vessel lesions: Lumen, plaque, and hemodynamic insights from coronary CT angiography.
Authors
Affiliations (45)
Affiliations (45)
- Seoul National University College of Medicine and Seoul National University Hospital, Seoul, South Korea.
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
- Division of Cardiology, Department of Medicine, Gangneung Asan Hospital, South Korea.
- Department of Cardiology, Eulji University Medical Center, Daejeon, South Korea.
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea.
- Department of Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea.
- Department of Cardiology, Ulsan Medical Center, Ulsan, South Korea.
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea.
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, South Korea.
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea.
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, South Korea.
- Department of Cardiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea.
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.
- Division of Cardiology, Department of Internal Medicine, Jeju National University Hospital, Jeju, South Korea.
- Department of Cardiology, Odense University Hospital, Svendborg, Denmark.
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
- Division of University Cardiology, IRCCS Ospedale Galeazzi Sant'Ambrogio, Department of Clinical and Biomedical Sciences, University of Milan, Italy.
- Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary.
- The Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
- Cardiovascular Center Aalst, Onze Lieve Vrouwziekenhuis-Clinic, Aalst, Belgium.
- Monash Cardiovascular Research Centre, Monash University and Monash Heart, Monash Health, Clayton, Victoria, Australia.
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada.
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Centro Integral de Enfermedades Cardiovasculares (CIEC), Hospital Universitario HM Montepríncipe, Madrid, Spain; Atriaclinic, Madrid, Spain.
- Division of Cardiology, Loyola University Chicago, Chicago, IL, USA.
- Department of Cardiology, Washington University School of Medicine, St. Louis, MI, USA.
- Department of Cardiology, Allegheny General Hospital, Pittsburgh, PA, USA.
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan.
- Cardiovascular Center, St Luke's International Hospital, Tokyo, Japan.
- Department of Cardiovascular Medicine, Toyohashi Heart Center, Aichi, Japan.
- Department of Cardiology, Aichi Medical University, Nagakute, Japan.
- Department of Cardiovascular Medicine, Gifu Heart Center, Gifu, Japan.
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan.
- Department of Radiology, Ehime University Graduate School of Medicine, Ehime, Japan.
- Cardiovascular Center, Fukuoka Sanno Hospital, Fukuoka, Japan.
- Cardiovascular Center, Shin-Koga Hospital, Kurume, Japan.
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan.
- Department of Cardiovascular Medicine, Institute of Science Tokyo, Tokyo, Japan.
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Ibaraki, Japan.
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Japan.
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, Leiden, the Netherlands.
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Heart & Vascular Institute, McGovern Medical School, University of Texas Health Sciences Center, Houston, TX, USA.
- Seoul National University College of Medicine and Seoul National University Hospital, Seoul, South Korea. Electronic address: [email protected].
Abstract
Risk assessment of coronary side branch (SB) lesions remains challenging because stenosis-based assessment alone often fails to identify clinically relevant lesions. To characterize SB lesions associated with acute coronary syndrome (ACS), evaluate the performance of conventional main vessel (MV)-derived high-risk plaque criteria in SB lesions, and identify independent SB predictors of ACS. We analyzed 2451 coronary lesions (2011 MV, 440 SB) from the EMERALD-II study, in which coronary CT angiography was performed 1-36 months before ACS using an AI-assisted quantitative analysis platform. Lesion characteristics included stenosis severity, plaque burden, adverse plaque characteristics (APCs), and the change in CT-derived fractional flow reserve across the lesion (ΔFFR<sub>CT</sub>). Diagnostic performance of conventional high-risk plaque criteria was compared between MV and SB lesions. Culprit lesions showed greater stenosis severity, plaque burden, APC count, and ΔFFR<sub>CT</sub> than non-culprit lesions in both vessels. However, these interrelationships were weaker in SB lesions. Among lesions meeting high-risk criteria, SB lesions were less often ACS culprits than MV lesions: ≥50% stenosis, 11.1% vs. 38.5%; plaque burden ≥70%, 8.6% vs. 23.8%; ≥2 APCs, 18.2% vs. 34.4%; and ΔFFR<sub>CT</sub> ≥0.10, 19.4% vs. 49.4%. Positive predictive values and F1-scores were consistently lower for SB lesions. APC count and ΔFFR<sub>CT</sub> were independent predictors of ACS in SB lesions. SB lesions had a substantially lower likelihood of subsequent ACS culprit status than equivalent MV lesions. These findings from AI-assisted CCTA analysis highlight the limitations of applying MV-derived thresholds to SB lesions and support the need for SB-specific risk assessment.