The Napkin-Ring Sign – the Story Behind Invasive Coronary Angiography

Abstract

Coronary artery disease (CAD) represents one of the leading causes of morbidity and mortality across Europe. Most of the patients do not experience any warning sign before the coronary event develops, therefore screening this group of patients is essential to prevent major cardiac events. Coronary computed tomography angiography (CCTA) offers a noninvasive approach of the coronary arteries, providing information not only on the presence and severity of the coronary stenosis, but is also able to characterize the structure of the coronary wall. CCTA allows complex evaluation of the extension of CAD, and by assessing the structure of the atherosclerotic plaque, it can identify its degree of vulnerability. The napkin-ring sign (NRS) represents a ring-like attenuation of the non-calcified portion of the coronary lesion and has a high specificity (96–100%) for the identification of thin cap fibroatheroma (TCFA) or culprit lesion in acute coronary syndromes (ACS). It is also an independent predictor for ACS events and the strongest predictor for future ACS. Modern CCTA can provide submillimeter isotropic spatial resolution. Thus, CT attenuation-based tissue interpretation enables the assessment of total coronary plaque burden and individual plaque components, with a similar accuracy as intravascular ultrasoud-based investigations. This review aims to present the important role of CCTA as a potent screening tool for patients with CAD, and the current evidences in the detection and quantification of vulnerable plaques.

A Race Against Time: Coronary Computed Tomography Angiography Discovers a Highly Inflamed Plaque in 49-Year-Old Right Before STEMI

“…This is based on the understanding that larger plaque volumes increase the risk of ruptures, potentially leading to myocardial infarction. 15,16 The specific type of plaque is equally important, as ruptures are more likely in inflamed plaques, which typically have thin fibrous caps and large necrotic cores, often associated with inflamed PVAT. 6,17 Additionally, the use of FAI mapping through CCTA is effective in detecting inflammation in PVAT, and its accuracy remains unaffected by the degree of coronary calcification, systemic inflammation, or the level of stenosis in the coronary lumen.…”