IMPORTANCE Distinct plaque locations and vessel geometric features predispose to altered coronary flow hemodynamics. The association between these lesion-level characteristics assessed by coronary computed tomographic angiography (CCTA) and risk of future acute coronary syndrome (ACS) is unknown. OBJECTIVE To examine whether CCTA-derived adverse geometric characteristics (AGCs) of coronary lesions describing location and vessel geometry add to plaque morphology and burden for identifying culprit lesion precursors associated with future ACS. DESIGN, SETTING, AND PARTICIPANTS This substudy of ICONIC (Incident Coronary Syndromes Identified by Computed Tomography), a multicenter nested case-control cohort study, included patients with ACS and a culprit lesion precursor identified on baseline CCTA (n = 116) and propensity score-matched non-ACS controls (n = 116). Data were collected from July 20, 2012, to April 30, 2017, and analyzed from October 1, 2020, to October 31, 2021. EXPOSURES Coronary lesions were evaluated for the following 3 AGCs: (1) distance from the coronary ostium to lesion; (2) location at vessel bifurcations; and (3) vessel tortuosity, defined as the presence of 1 bend of greater than 90° or 3 curves of 45° to 90° using a 3-point angle within the lesion. MAIN OUTCOMES AND MEASURES Association between lesion-level AGCs and risk of future ACS-causing culprit lesions. RESULTS Of 548 lesions, 116 culprit lesion precursors were identified in 116 patients (80 [69.0%] men; mean [SD], age 62.7 [11.5] years). Compared with nonculprit lesions, culprit lesion precursors had a shorter distance from the ostium (median, 35.1 [IQR, 23.6-48.4] mm vs 44.5 [IQR, 28.2-70.8] mm), more frequently localized to bifurcations (85 [73.3%] vs 168 [38.9%]), and had more tortuous vessel segments (5 [4.3%] vs 6 [1.4%]; all P < .05). In multivariable Cox regression analysis, an increasing number of AGCs was associated with a greater risk of future culprit lesions (hazard ratio [HR] for 1 AGC, 2.90 [95% CI, 1.38-6.08]; P = .005; HR for ≥2 AGCs, 6.84 [95% CI, 3.33-14.04]; P < .001). Adverse geometric characteristics provided incremental discriminatory value for culprit lesion precursors when added to a model containing stenosis severity, adverse morphological plaque characteristics, and quantitative plaque characteristics (area under the curve, 0.766 [95% CI, 0.718-0.814] vs 0.733 [95% CI, 0.685-0.782]). In per-patient comparison, patients with ACS had a higher frequency of lesions with adverse plaque characteristics, AGCs, or both compared with control patients (≥2 adverse plaque characteristics, 70 [60.3%] vs 50 [43.1%]; ≥2 AGCs, 92 [79.3%] vs 60 [51.7%]; ≥2 of both, 37 [31.9%] vs 20 [17.2%]; all P < .05). CONCLUSIONS AND RELEVANCE These findings support the concept that CCTA-derived AGCs capturing lesion location and vessel geometry are associated with risk of future ACS-causing culprit lesions. Adverse geometric characteristics may provide additive prognostic information beyond plaque assessment in CCTA.

中文翻译：

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冠状动脉计算机断层扫描血管造影确定的斑块位置和血管几何形状与未来引起急性冠状动脉综合征的罪魁祸首病变的关联。

重要性 不同的斑块位置和血管几何特征易导致冠脉血流动力学改变。通过冠状动脉计算机断层扫描血管造影 (CCTA) 评估的这些病变水平特征与未来发生急性冠状动脉综合征 (ACS) 的风险之间的关联尚不清楚。目的 检查 CCTA 衍生的描述位置和血管几何形状的冠状动脉病变的不良几何特征 (AGC) 是否会增加斑块形态和识别与未来 ACS 相关的罪魁祸首病变前体的负担。设计、地点和参与者 ICONIC（计算机断层扫描确定的冠状动脉综合征事件）的这项子研究是一项多中心巢式病例对照队列研究，包括 ACS 患者和在基线 CCTA 上确定的罪犯病变前体 (n = 116) 和倾向评分匹配的非 ACS 对照 (n = 116)。数据收集时间为 2012 年 7 月 20 日至 2017 年 4 月 30 日，分析时间为 2020 年 10 月 1 日至 2021 年 10 月 31 日。暴露 冠状动脉病变评估了以下 3 个 AGC：(1) 从冠状动脉开口到病变的距离; (2) 血管分叉处的位置；(3) 血管迂曲，定义为在病灶内使用 3 点角存在 1 个大于 90° 的弯曲或 3 个 45° 至 90° 的弯曲。主要结果和测量 病变水平 AGC 与未来导致 ACS 的罪魁祸首病变风险之间的关联。结果 在 548 个病变中，116 名患者（80 [69.0%] 男性；平均 [SD]，年龄 62.7 [11.5] 岁）确定了 116 个罪犯病变前体。与非罪犯病变相比，罪犯病变前体与开口的距离较短（中位数，35.1 [IQR，23.6-48.4] mm vs 44.5 [IQR，28.2-70.8] mm），更常位于分叉处（85 [73.3%] vs 168 [38.9%] ])，并且有更多弯曲的血管段（5 [4.3%] 对比 6 [1.4%]；所有 P < .05）。在多变量 Cox 回归分析中，AGC 数量的增加与未来罪魁祸首病变的风险增加相关（1 个 AGC 的风险比 [HR]，2.90 [95% CI，1.38-6.08]；P = .005；HR ≥ 2 AGC，6.84 [95% CI，3.33-14.04]；P < .001）。当添加到包含狭窄严重程度、不利形态学斑块特征和定量斑块特征（曲线下面积，0.766 [95% CI，0.718-0.814] 对 0.733 [95%置信区间，0.685-0。782]）。在每位患者的比较中，与对照组患者相比，ACS 患者具有不良斑块特征、AGC 或两者的病变频率更高（≥2 个不良斑块特征，70 [60.3%] 对 50 [43.1%]；≥2 个 AGC , 92 [79.3%] vs 60 [51.7%]；两者≥2，37 [31.9%] vs 20 [17.2%]；所有 P < .05）。结论和相关性 这些发现支持这样的概念，即捕获病变位置和血管几何形状的 CCTA 衍生的 AGC 与未来导致 ACS 的罪魁祸首病变的风险相关。除了 CCTA 中的斑块评估之外，不利的几何特征可能会提供额外的预后信息。92 [79.3%] 对 60 [51.7%]；两者≥2，37 [31.9%] vs 20 [17.2%]；所有 P < .05）。结论和相关性 这些发现支持这样的概念，即捕获病变位置和血管几何形状的 CCTA 衍生的 AGC 与未来导致 ACS 的罪魁祸首病变的风险相关。除了 CCTA 中的斑块评估之外，不利的几何特征可能会提供额外的预后信息。92 [79.3%] 对 60 [51.7%]；两者≥2，37 [31.9%] vs 20 [17.2%]；所有 P < .05）。结论和相关性 这些发现支持这样的概念，即捕获病变位置和血管几何形状的 CCTA 衍生的 AGC 与未来导致 ACS 的罪魁祸首病变的风险相关。除了 CCTA 中的斑块评估之外，不利的几何特征可能会提供额外的预后信息。