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Incremental prognostic value of coronary computed tomographic angiography over coronary artery calcium score for risk prediction of major adverse cardiac events in asymptomatic diabetic individuals.
Atherosclerosis. 2014 Feb; 232(2):298-304.A

Abstract

BACKGROUND

Coronary artery disease (CAD) diagnosis by coronary computed tomographic angiography (CCTA) is useful for identification of symptomatic diabetic individuals at heightened risk for death. Whether CCTA-detected CAD enables improved risk assessment of asymptomatic diabetic individuals beyond clinical risk factors and coronary artery calcium scoring (CACS) remains unexplored.

METHODS

From a prospective 12-center international registry of 27,125 individuals undergoing CCTA, we identified 400 asymptomatic diabetic individuals without known CAD. Coronary stenosis by CCTA was graded as 0%, 1-49%, 50-69%, and ≥70%. CAD was judged on a per-patient, per-vessel and per-segment basis as maximal stenosis severity, number of vessels with ≥50% stenosis, and coronary segments weighted for stenosis severity (segment stenosis score), respectively. We assessed major adverse cardiovascular events (MACE) - inclusive of mortality, nonfatal myocardial infarction (MI), and late target vessel revascularization ≥90 days (REV) - and evaluated the incremental utility of CCTA for risk prediction, discrimination and reclassification.

RESULTS

Mean age was 60.4 ± 9.9 years; 65.0% were male. At a mean follow-up 2.4 ± 1.1 years, 33 MACE occurred (13 deaths, 8 MI, 12 REV) [8.25%; annualized rate 3.4%]. By univariate analysis, per-patient maximal stenosis [hazards ratio (HR) 2.24 per stenosis grade, 95% confidence interval (CI) 1.61-3.10, p < 0.001], increasing numbers of obstructive vessels (HR 2.30 per vessel, 95% CI 1.75-3.03, p < 0.001) and segment stenosis score (HR 1.14 per segment, 95% CI 1.09-1.19, p < 0.001) were associated with increased MACE. After adjustment for CAD risk factors and CACS, maximal stenosis (HR 1.80 per grade, 95% CI 1.18-2.75, p = 0.006), number of obstructive vessels (HR 1.85 per vessel, 95% CI 1.29-2.65, p < 0.001) and segment stenosis score (HR 1.11 per segment, 95% CI 1.05-1.18, p < 0.001) were associated with increased risk of MACE. Beyond age, gender and CACS (C-index 0.64), CCTA improved discrimination by maximal stenosis, number of obstructive vessels and segment stenosis score (C-index 0.77, 0.77 and 0.78, respectively). Similarly, CCTA findings improved risk reclassification by per-patient maximal stenosis [integrated discrimination improvement (IDI) index 0.03, p = 0.03] and number of obstructive vessels (IDI index 0.06, p = 0.002), and by trend for segment stenosis score (IDI 0.03, p = 0.06).

CONCLUSION

For asymptomatic diabetic individuals, CCTA measures of CAD severity confer incremental risk prediction, discrimination and reclassification on a per-patient, per-vessel and per-segment basis.

Authors+Show Affiliations

Department of Radiology, Weill Cornell Medical College and The NewYork-Presbyterian Hospital, New York, NY, USA. Electronic address: james.min@cshs.org.Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA.Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA.Department of Medicine, University of Erlangen, Erlangen, Germany.Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI, USA.Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA, USA.Department of Radiology, Giovanni XXIII Hospital, Monastier, Treviso, Italy; Department of Radiology, Erasmus Medical Center, Rotterdam, Netherlands.Tennessee Heart and Vascular Institute, Hendersonville, TN, USA.Division of Cardiology, Severance Cardiovascular Hospital, Seoul, South Korea.Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA.William Beaumont Hospital, Royal Oak, MI, USA.Department of Medicine and Radiology, University of Ottawa, Ontario, Canada.Baptist Cardiac and Vascular Institute, Miami, FL, USA.Capitol Cardiology Associates, Albany, NY, USA.Department of Public Health, Weill Cornell Medical College, New York, NY, USA.Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.University of Munich, Munich, Germany.Cardiovascular Medical Group, Los Angeles, CA, USA.University Hospital, Zurich, Switzerland.Seoul National University Hospital, Seoul, South Korea.Department of Medicine and Radiology, University of British Columbia, Vancouver, BC, Canada.Department of Medicine, Weill Cornell Medical College, New York, NY, USA.Department of Radiology, Giovanni XXIII Hospital, Monastier, Treviso, Italy; Department of Radiology, Erasmus Medical Center, Rotterdam, Netherlands.William Beaumont Hospital, Royal Oak, MI, USA.Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.Walter Reed Medical Center, Bethesda, MD, USA.Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Pub Type(s)

Journal Article
Multicenter Study
Observational Study

Language

eng

PubMed ID

24468142

Citation

Min, James K., et al. "Incremental Prognostic Value of Coronary Computed Tomographic Angiography Over Coronary Artery Calcium Score for Risk Prediction of Major Adverse Cardiac Events in Asymptomatic Diabetic Individuals." Atherosclerosis, vol. 232, no. 2, 2014, pp. 298-304.
Min JK, Labounty TM, Gomez MJ, et al. Incremental prognostic value of coronary computed tomographic angiography over coronary artery calcium score for risk prediction of major adverse cardiac events in asymptomatic diabetic individuals. Atherosclerosis. 2014;232(2):298-304.
Min, J. K., Labounty, T. M., Gomez, M. J., Achenbach, S., Al-Mallah, M., Budoff, M. J., Cademartiri, F., Callister, T. Q., Chang, H. J., Cheng, V., Chinnaiyan, K. M., Chow, B., Cury, R., Delago, A., Dunning, A., Feuchtner, G., Hadamitzky, M., Hausleiter, J., Kaufmann, P., ... Berman, D. S. (2014). Incremental prognostic value of coronary computed tomographic angiography over coronary artery calcium score for risk prediction of major adverse cardiac events in asymptomatic diabetic individuals. Atherosclerosis, 232(2), 298-304. https://doi.org/10.1016/j.atherosclerosis.2013.09.025
Min JK, et al. Incremental Prognostic Value of Coronary Computed Tomographic Angiography Over Coronary Artery Calcium Score for Risk Prediction of Major Adverse Cardiac Events in Asymptomatic Diabetic Individuals. Atherosclerosis. 2014;232(2):298-304. PubMed PMID: 24468142.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Incremental prognostic value of coronary computed tomographic angiography over coronary artery calcium score for risk prediction of major adverse cardiac events in asymptomatic diabetic individuals. AU - Min,James K, AU - Labounty,Troy M, AU - Gomez,Millie J, AU - Achenbach,Stephan, AU - Al-Mallah,Mouaz, AU - Budoff,Matthew J, AU - Cademartiri,Filippo, AU - Callister,Tracy Q, AU - Chang,Hyuk-Jae, AU - Cheng,Victor, AU - Chinnaiyan,Kavitha M, AU - Chow,Benjamin, AU - Cury,Ricardo, AU - Delago,Augustin, AU - Dunning,Allison, AU - Feuchtner,Gudrun, AU - Hadamitzky,Martin, AU - Hausleiter,Jorg, AU - Kaufmann,Philipp, AU - Kim,Yong-Jin, AU - Leipsic,Jonathon, AU - Lin,Fay Y, AU - Maffei,Erica, AU - Raff,Gilbert, AU - Shaw,Leslee J, AU - Villines,Todd C, AU - Berman,Daniel S, Y1 - 2013/10/29/ PY - 2013/04/17/received PY - 2013/09/09/revised PY - 2013/09/22/accepted PY - 2014/1/29/entrez PY - 2014/1/29/pubmed PY - 2014/9/30/medline KW - Coronary CT angiography KW - Coronary artery calcium score KW - Coronary artery disease KW - Major adverse cardiac events SP - 298 EP - 304 JF - Atherosclerosis JO - Atherosclerosis VL - 232 IS - 2 N2 - BACKGROUND: Coronary artery disease (CAD) diagnosis by coronary computed tomographic angiography (CCTA) is useful for identification of symptomatic diabetic individuals at heightened risk for death. Whether CCTA-detected CAD enables improved risk assessment of asymptomatic diabetic individuals beyond clinical risk factors and coronary artery calcium scoring (CACS) remains unexplored. METHODS: From a prospective 12-center international registry of 27,125 individuals undergoing CCTA, we identified 400 asymptomatic diabetic individuals without known CAD. Coronary stenosis by CCTA was graded as 0%, 1-49%, 50-69%, and ≥70%. CAD was judged on a per-patient, per-vessel and per-segment basis as maximal stenosis severity, number of vessels with ≥50% stenosis, and coronary segments weighted for stenosis severity (segment stenosis score), respectively. We assessed major adverse cardiovascular events (MACE) - inclusive of mortality, nonfatal myocardial infarction (MI), and late target vessel revascularization ≥90 days (REV) - and evaluated the incremental utility of CCTA for risk prediction, discrimination and reclassification. RESULTS: Mean age was 60.4 ± 9.9 years; 65.0% were male. At a mean follow-up 2.4 ± 1.1 years, 33 MACE occurred (13 deaths, 8 MI, 12 REV) [8.25%; annualized rate 3.4%]. By univariate analysis, per-patient maximal stenosis [hazards ratio (HR) 2.24 per stenosis grade, 95% confidence interval (CI) 1.61-3.10, p < 0.001], increasing numbers of obstructive vessels (HR 2.30 per vessel, 95% CI 1.75-3.03, p < 0.001) and segment stenosis score (HR 1.14 per segment, 95% CI 1.09-1.19, p < 0.001) were associated with increased MACE. After adjustment for CAD risk factors and CACS, maximal stenosis (HR 1.80 per grade, 95% CI 1.18-2.75, p = 0.006), number of obstructive vessels (HR 1.85 per vessel, 95% CI 1.29-2.65, p < 0.001) and segment stenosis score (HR 1.11 per segment, 95% CI 1.05-1.18, p < 0.001) were associated with increased risk of MACE. Beyond age, gender and CACS (C-index 0.64), CCTA improved discrimination by maximal stenosis, number of obstructive vessels and segment stenosis score (C-index 0.77, 0.77 and 0.78, respectively). Similarly, CCTA findings improved risk reclassification by per-patient maximal stenosis [integrated discrimination improvement (IDI) index 0.03, p = 0.03] and number of obstructive vessels (IDI index 0.06, p = 0.002), and by trend for segment stenosis score (IDI 0.03, p = 0.06). CONCLUSION: For asymptomatic diabetic individuals, CCTA measures of CAD severity confer incremental risk prediction, discrimination and reclassification on a per-patient, per-vessel and per-segment basis. SN - 1879-1484 UR - https://www.unboundmedicine.com/medline/citation/24468142/Incremental_prognostic_value_of_coronary_computed_tomographic_angiography_over_coronary_artery_calcium_score_for_risk_prediction_of_major_adverse_cardiac_events_in_asymptomatic_diabetic_individuals_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0021-9150(13)00571-6 DB - PRIME DP - Unbound Medicine ER -