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13 reviewsABSTRACTKeywords:Background: Both coronary atherosclerotic plaque activity and low endothelial shear stress (ESS) are predictive ofEndothelial shear stressadverse cardiovascular events. We aimed to investigate their association and relationship with high-risk plaqueComputational fluid dynamicsfeatures.Coronary atherosclerotic plaque activityMethods: Coronary computed tomography angiography (CCTA) based flow simulations were used to compute ESSPositron emission tomographyin patients presenting with acute coronary syndrome proceeding percutaneous coronary intervention. AssociaCoronary computed tomographic angiographytions between ESS, CCTA plaque features and coronary plaque activity, measured by 18F-sodium fluoride(18F–NaF) positron emission tomography (PET), were investigated at the coronary segment and vessel level.Results: ESS and coronary plaque activity were both analyzed in 330 coronary segments and 123 vessels. The areaof low ESS (<0.4 Pa), termed low shear area (LSA), was larger in 18F–NaF positive regions increasing from median11.7 mm2 (IQR: 4.6–27.4) to 29.0 mm2 (IQR: 14.1–55.2) at the segment level (P < 0.0001) and from median 27.3mm2 (IQR: 8.6–65.3) to 57.8 mm2 (26.6–108.2) at the vessel level (P ¼ 0.0049). The maximum tissue-tobackground ratio of 18F–NaF activity positively correlated with LSA at the segment level (rs ¼ 0.27; P <0.0001) and at the vessel level (rs ¼ 0.38; P < 0.0001). LSA was associated with spotty calcification at both thesegment (P <0.0001) and vessel level (P ¼ 0.0042) and positive remodeling at the vessel level (P ¼ 0.025).Conclusions: In patients with acute coronary syndrome, LSA is associated with increased coronary atheroscleroticplaque activity, as measured by 18F–NaF PET.Abbreviations: ACS, Acute coronary syndrome; CAD, Coronary artery disease; CCTA, Coronary computed tomography angiography; CFD, Computational fluiddynamics; ECG, Electrocardiogram; ESS, Endothelial shear stress; 18F–NaF, 18F-Sodium fluoride; GRACE, Global Registry of Acute Coronary Events; HSA, High sheararea; HU, Hounsfield unit; IVUS, Intravascular ultrasound; LSA, Low shear area; LAP, Low attenuation plaque; OCT, Optical coherence tomography; PCI, Percutaneouscoronary intervention; PET, Positron emission tomography; SC, Spotty calcification; SUV, Standardized uptake value; TBR, Tissue-to-background ratio.* Corresponding author. Level 13, 256 Adelaide Terrace, Perth, 6000, Australia.E-mail address: [email protected] (J.K. Tapley).