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Incremental prognostic utility of coronary CT angiography for asymptomatic patients based upon extent and severity of coronary artery calcium: results from the COronary CT Angiography EvaluatioN For Clinical Outcomes InteRnational Multicenter (CONFIRM) study.
Eur Heart J. 2015 Feb 21; 36(8):501-8.EH

Abstract

AIM

Prior evidence observed no predictive utility of coronary CT angiography (CCTA) over the coronary artery calcium score (CACS) and the Framingham risk score (FRS), among asymptomatic individuals. Whether the prognostic value of CCTA differs for asymptomatic patients, when stratified by CACS severity, remains unknown.

METHODS AND RESULTS

From a 12-centre, 6-country observational registry, 3217 asymptomatic individuals without known coronary artery disease (CAD) underwent CACS and CCTA. Individuals were categorized by CACS as: 0-10, 11-100, 101-400, 401-1000, >1000. For CCTA analysis, the number of obstructive vessels-as defined by the per-patient presence of a ≥50% luminal stenosis-was used to grade the extent and severity of CAD. The incremental prognostic value of CCTA over and above FRS was measured by the likelihood ratio (LR) χ(2), C-statistic, and continuous net reclassification improvement (NRI) for prediction, discrimination, and reclassification of all-cause mortality and non-fatal myocardial infarction. During a median follow-up of 24 months (25th-75th percentile, 17-30 months), there were 58 composite end-points. The incremental value of CCTA over FRS was demonstrated in individuals with CACS >100 (LRχ(2), 25.34; increment in C-statistic, 0.24; NRI, 0.62, all P < 0.001), but not among those with CACS ≤100 (all P > 0.05). For subgroups with CACS >100, the utility of CCTA for predicting the study end-point was evident among individuals whose CACS ranged from 101 to 400; the observed predictive benefit attenuated with increasing CACS.

CONCLUSION

Coronary CT angiography provides incremental prognostic utility for prediction of mortality and non-fatal myocardial infarction for asymptomatic individuals with moderately high CACS, but not for lower or higher CACS.

Authors+Show Affiliations

Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno Seodaemungu, Seoul, South Korea Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA.Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno Seodaemungu, Seoul, South Korea hjchang@yuhs.ac.Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA.Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno Seodaemungu, Seoul, South Korea.Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno Seodaemungu, Seoul, South Korea.Department of Medicine, NewYork-Presbyterian Hospital and Weill Cornell Medical College, New York, NY, USA.Department of Medicine, University of Erlangen, Erlangen, Germany.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, Harbor UCLA Medical Center, Los Angeles, CA, USA.Tennessee Heart and Vascular Institute, Hendersonville, TN, USA.Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI, USA.Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands.William Beaumont Hospital, Royal Oaks, MI, USA.Department of Medicine and Radiology, University of Ottawa, Ottawa, ON, Canada.Duke Clinical Research Institute, Durham, NC, USA.Capitol Cardiology Associates, Albany, NY, USA.Department of Medicine, Walter Reed Medical Center, Washington, DC, USA.Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany.Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany.Department of Medicine and Radiology, University of British Columbia, Vancouver, BC, Canada.Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.University Hospital, Zurich, Switzerland.Baptist Cardiac and Vascular Institute, Miami, FL, USA.Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.Seoul National University Hospital, Seoul, South Korea.Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands.William Beaumont Hospital, Royal Oaks, MI, USA.Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy.Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy.Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA.

Pub Type(s)

Journal Article
Multicenter Study
Observational Study
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

25205531

Citation

Cho, Iksung, et al. "Incremental Prognostic Utility of Coronary CT Angiography for Asymptomatic Patients Based Upon Extent and Severity of Coronary Artery Calcium: Results From the COronary CT Angiography EvaluatioN for Clinical Outcomes InteRnational Multicenter (CONFIRM) Study." European Heart Journal, vol. 36, no. 8, 2015, pp. 501-8.
Cho I, Chang HJ, Ó Hartaigh B, et al. Incremental prognostic utility of coronary CT angiography for asymptomatic patients based upon extent and severity of coronary artery calcium: results from the COronary CT Angiography EvaluatioN For Clinical Outcomes InteRnational Multicenter (CONFIRM) study. Eur Heart J. 2015;36(8):501-8.
Cho, I., Chang, H. J., Ó Hartaigh, B., Shin, S., Sung, J. M., Lin, F. Y., Achenbach, S., Heo, R., Berman, D. S., Budoff, M. J., Callister, T. Q., Al-Mallah, M. H., Cademartiri, F., Chinnaiyan, K., Chow, B. J., Dunning, A. M., DeLago, A., Villines, T. C., Hadamitzky, M., ... Min, J. K. (2015). Incremental prognostic utility of coronary CT angiography for asymptomatic patients based upon extent and severity of coronary artery calcium: results from the COronary CT Angiography EvaluatioN For Clinical Outcomes InteRnational Multicenter (CONFIRM) study. European Heart Journal, 36(8), 501-8. https://doi.org/10.1093/eurheartj/ehu358
Cho I, et al. Incremental Prognostic Utility of Coronary CT Angiography for Asymptomatic Patients Based Upon Extent and Severity of Coronary Artery Calcium: Results From the COronary CT Angiography EvaluatioN for Clinical Outcomes InteRnational Multicenter (CONFIRM) Study. Eur Heart J. 2015 Feb 21;36(8):501-8. PubMed PMID: 25205531.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Incremental prognostic utility of coronary CT angiography for asymptomatic patients based upon extent and severity of coronary artery calcium: results from the COronary CT Angiography EvaluatioN For Clinical Outcomes InteRnational Multicenter (CONFIRM) study. AU - Cho,Iksung, AU - Chang,Hyuk-Jae, AU - Ó Hartaigh,Bríain, AU - Shin,Sanghoon, AU - Sung,Ji Min, AU - Lin,Fay Y, AU - Achenbach,Stephan, AU - Heo,Ran, AU - Berman,Daniel S, AU - Budoff,Matthew J, AU - Callister,Tracy Q, AU - Al-Mallah,Mouaz H, AU - Cademartiri,Filippo, AU - Chinnaiyan,Kavitha, AU - Chow,Benjamin J W, AU - Dunning,Allison M, AU - DeLago,Augustin, AU - Villines,Todd C, AU - Hadamitzky,Martin, AU - Hausleiter,Joerg, AU - Leipsic,Jonathon, AU - Shaw,Leslee J, AU - Kaufmann,Philipp A, AU - Cury,Ricardo C, AU - Feuchtner,Gudrun, AU - Kim,Yong-Jin, AU - Maffei,Erica, AU - Raff,Gilbert, AU - Pontone,Gianluca, AU - Andreini,Daniele, AU - Min,James K, Y1 - 2014/09/08/ PY - 2014/9/11/entrez PY - 2014/9/11/pubmed PY - 2015/12/15/medline KW - Asymptomatic KW - Coronary artery calcium scoring KW - Coronary computed tomographic angiography KW - Framingham risk score KW - Prognostic SP - 501 EP - 8 JF - European heart journal JO - Eur Heart J VL - 36 IS - 8 N2 - AIM: Prior evidence observed no predictive utility of coronary CT angiography (CCTA) over the coronary artery calcium score (CACS) and the Framingham risk score (FRS), among asymptomatic individuals. Whether the prognostic value of CCTA differs for asymptomatic patients, when stratified by CACS severity, remains unknown. METHODS AND RESULTS: From a 12-centre, 6-country observational registry, 3217 asymptomatic individuals without known coronary artery disease (CAD) underwent CACS and CCTA. Individuals were categorized by CACS as: 0-10, 11-100, 101-400, 401-1000, >1000. For CCTA analysis, the number of obstructive vessels-as defined by the per-patient presence of a ≥50% luminal stenosis-was used to grade the extent and severity of CAD. The incremental prognostic value of CCTA over and above FRS was measured by the likelihood ratio (LR) χ(2), C-statistic, and continuous net reclassification improvement (NRI) for prediction, discrimination, and reclassification of all-cause mortality and non-fatal myocardial infarction. During a median follow-up of 24 months (25th-75th percentile, 17-30 months), there were 58 composite end-points. The incremental value of CCTA over FRS was demonstrated in individuals with CACS >100 (LRχ(2), 25.34; increment in C-statistic, 0.24; NRI, 0.62, all P < 0.001), but not among those with CACS ≤100 (all P > 0.05). For subgroups with CACS >100, the utility of CCTA for predicting the study end-point was evident among individuals whose CACS ranged from 101 to 400; the observed predictive benefit attenuated with increasing CACS. CONCLUSION: Coronary CT angiography provides incremental prognostic utility for prediction of mortality and non-fatal myocardial infarction for asymptomatic individuals with moderately high CACS, but not for lower or higher CACS. SN - 1522-9645 UR - https://www.unboundmedicine.com/medline/citation/25205531/Incremental_prognostic_utility_of_coronary_CT_angiography_for_asymptomatic_patients_based_upon_extent_and_severity_of_coronary_artery_calcium:_results_from_the_COronary_CT_Angiography_EvaluatioN_For_Clinical_Outcomes_InteRnational_Multicenter__CONFIRM__study_ DB - PRIME DP - Unbound Medicine ER -