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Does coronary CT angiography improve risk stratification over coronary calcium scoring in symptomatic patients with suspected coronary artery disease? Results from the prospective multicenter international CONFIRM registry.
Eur Heart J Cardiovasc Imaging. 2014 Mar; 15(3):267-74.EH

Abstract

AIMS

The prognostic value of coronary artery calcium (CAC) scoring is well established and has been suggested for use to exclude significant coronary artery disease (CAD) for symptomatic individuals with CAD. Contrast-enhanced coronary computed tomographic angiography (CCTA) is an alternative modality that enables direct visualization of coronary stenosis severity, extent, and distribution. Whether CCTA findings of CAD add an incremental prognostic value over CAC in symptomatic individuals has not been extensively studied.

METHODS AND RESULTS

We prospectively identified symptomatic patients with suspected but without known CAD who underwent both CAC and CCTA. Symptoms were defined by the presence of chest pain or dyspnoea, and pre-test likelihood of obstructive CAD was assessed by the method of Diamond and Forrester (D-F). CAC was measured by the method of Agatston. CCTAs were graded for obstructive CAD (>70% stenosis); and CAD plaque burden, distribution, and location. Plaque burden was determined by a segment stenosis score (SSS), which reflects the number of coronary segments with plaque, weighted for stenosis severity. Plaque distribution was established by a segment-involvement score (SIS), which reflects the number of segments with plaque irrespective of stenosis severity. Finally, a modified Duke prognostic index-accounting for stenosis severity, plaque distribution, and plaque location-was calculated. Nested Cox proportional hazard models for a composite endpoint of all-cause mortality and non-fatal myocardial infarction (D/MI) were employed to assess the incremental prognostic value of CCTA over CAC. A total of 8627 symptomatic patients (50% men, age 56 ± 12 years) followed for 25 months (interquartile range 17-40 months) comprised the study cohort. By CAC, 4860 (56%) and 713 (8.3%) patients had no evident calcium or a score of >400, respectively. By CCTA, 4294 (49.8%) and 749 (8.7%) had normal coronary arteries or obstructive CAD, respectively. At follow-up, 150 patients experienced D/MI. CAC improved discrimination beyond D-F and clinical variables (area under the receiver-operator characteristic curve 0.781 vs. 0.788, P = 0.004). When added sequentially to D-F, clinical variables, and CAC, all CCTA measures of CAD improved discrimination of patients at risk for D/MI: obstructive CAD (0.82, P < 0.001), SSS (0.81, P < 0.001), SIS (0.81, P = 0.003), and Duke CAD prognostic index (0.82, P < 0.0001).

CONCLUSION

In symptomatic patients with suspected CAD, CCTA adds incremental discriminatory power over CAC for discrimination of individuals at risk of death or MI.

Authors+Show Affiliations

Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Multicenter Study

Language

eng

PubMed ID

23966421

Citation

Al-Mallah, Mouaz H., et al. "Does Coronary CT Angiography Improve Risk Stratification Over Coronary Calcium Scoring in Symptomatic Patients With Suspected Coronary Artery Disease? Results From the Prospective Multicenter International CONFIRM Registry." European Heart Journal Cardiovascular Imaging, vol. 15, no. 3, 2014, pp. 267-74.
Al-Mallah MH, Qureshi W, Lin FY, et al. Does coronary CT angiography improve risk stratification over coronary calcium scoring in symptomatic patients with suspected coronary artery disease? Results from the prospective multicenter international CONFIRM registry. Eur Heart J Cardiovasc Imaging. 2014;15(3):267-74.
Al-Mallah, M. H., Qureshi, W., Lin, F. Y., Achenbach, S., Berman, D. S., Budoff, M. J., Callister, T. Q., Chang, H. J., Cademartiri, F., Chinnaiyan, K., Chow, B. J., Cheng, V. Y., Delago, A., Gomez, M., Hadamitzky, M., Hausleiter, J., Kaufmann, P. A., Leipsic, J., Maffei, E., ... Min, J. K. (2014). Does coronary CT angiography improve risk stratification over coronary calcium scoring in symptomatic patients with suspected coronary artery disease? Results from the prospective multicenter international CONFIRM registry. European Heart Journal Cardiovascular Imaging, 15(3), 267-74. https://doi.org/10.1093/ehjci/jet148
Al-Mallah MH, et al. Does Coronary CT Angiography Improve Risk Stratification Over Coronary Calcium Scoring in Symptomatic Patients With Suspected Coronary Artery Disease? Results From the Prospective Multicenter International CONFIRM Registry. Eur Heart J Cardiovasc Imaging. 2014;15(3):267-74. PubMed PMID: 23966421.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Does coronary CT angiography improve risk stratification over coronary calcium scoring in symptomatic patients with suspected coronary artery disease? Results from the prospective multicenter international CONFIRM registry. AU - Al-Mallah,Mouaz H, AU - Qureshi,Waqas, AU - Lin,Fay Y, AU - Achenbach,Stephan, AU - Berman,Daniel S, AU - Budoff,Matthew J, AU - Callister,Tracy Q, AU - Chang,Hyuk-Jae, AU - Cademartiri,Filippo, AU - Chinnaiyan,Kavitha, AU - Chow,Benjamin J W, AU - Cheng,Victor Y, AU - Delago,Augustin, AU - Gomez,Millie, AU - Hadamitzky,Martin, AU - Hausleiter,Joerg, AU - Kaufmann,Philipp A, AU - Leipsic,Jonathon, AU - Maffei,Erica, AU - Raff,Gilbert, AU - Shaw,Leslee J, AU - Villines,Todd C, AU - Cury,Ricardo C, AU - Feuchtner,Gudrun, AU - Plank,Fabian, AU - Kim,Yong-Jin, AU - Dunning,Allison M, AU - Min,James K, Y1 - 2013/08/21/ PY - 2013/8/23/entrez PY - 2013/8/24/pubmed PY - 2014/11/5/medline KW - coronary CT angiography KW - coronary artery calcium KW - coronary artery disease KW - prognosis KW - symptomatic SP - 267 EP - 74 JF - European heart journal cardiovascular Imaging JO - Eur Heart J Cardiovasc Imaging VL - 15 IS - 3 N2 - AIMS: The prognostic value of coronary artery calcium (CAC) scoring is well established and has been suggested for use to exclude significant coronary artery disease (CAD) for symptomatic individuals with CAD. Contrast-enhanced coronary computed tomographic angiography (CCTA) is an alternative modality that enables direct visualization of coronary stenosis severity, extent, and distribution. Whether CCTA findings of CAD add an incremental prognostic value over CAC in symptomatic individuals has not been extensively studied. METHODS AND RESULTS: We prospectively identified symptomatic patients with suspected but without known CAD who underwent both CAC and CCTA. Symptoms were defined by the presence of chest pain or dyspnoea, and pre-test likelihood of obstructive CAD was assessed by the method of Diamond and Forrester (D-F). CAC was measured by the method of Agatston. CCTAs were graded for obstructive CAD (>70% stenosis); and CAD plaque burden, distribution, and location. Plaque burden was determined by a segment stenosis score (SSS), which reflects the number of coronary segments with plaque, weighted for stenosis severity. Plaque distribution was established by a segment-involvement score (SIS), which reflects the number of segments with plaque irrespective of stenosis severity. Finally, a modified Duke prognostic index-accounting for stenosis severity, plaque distribution, and plaque location-was calculated. Nested Cox proportional hazard models for a composite endpoint of all-cause mortality and non-fatal myocardial infarction (D/MI) were employed to assess the incremental prognostic value of CCTA over CAC. A total of 8627 symptomatic patients (50% men, age 56 ± 12 years) followed for 25 months (interquartile range 17-40 months) comprised the study cohort. By CAC, 4860 (56%) and 713 (8.3%) patients had no evident calcium or a score of >400, respectively. By CCTA, 4294 (49.8%) and 749 (8.7%) had normal coronary arteries or obstructive CAD, respectively. At follow-up, 150 patients experienced D/MI. CAC improved discrimination beyond D-F and clinical variables (area under the receiver-operator characteristic curve 0.781 vs. 0.788, P = 0.004). When added sequentially to D-F, clinical variables, and CAC, all CCTA measures of CAD improved discrimination of patients at risk for D/MI: obstructive CAD (0.82, P < 0.001), SSS (0.81, P < 0.001), SIS (0.81, P = 0.003), and Duke CAD prognostic index (0.82, P < 0.0001). CONCLUSION: In symptomatic patients with suspected CAD, CCTA adds incremental discriminatory power over CAC for discrimination of individuals at risk of death or MI. SN - 2047-2412 UR - https://www.unboundmedicine.com/medline/citation/23966421/Does_coronary_CT_angiography_improve_risk_stratification_over_coronary_calcium_scoring_in_symptomatic_patients_with_suspected_coronary_artery_disease_Results_from_the_prospective_multicenter_international_CONFIRM_registry_ L2 - https://academic.oup.com/ehjcimaging/article-lookup/doi/10.1093/ehjci/jet148 DB - PRIME DP - Unbound Medicine ER -