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Prognostic and therapeutic implications of statin and aspirin therapy in individuals with nonobstructive coronary artery disease: results from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter registry) registry.
Arterioscler Thromb Vasc Biol. 2015 Apr; 35(4):981-9.AT

Abstract

OBJECTIVE

We sought to examine the risk of mortality associated with nonobstructive coronary artery disease (CAD) and to determine the impact of baseline statin and aspirin use on mortality.

APPROACH AND RESULTS

Coronary computed tomographic angiography permits direct visualization of nonobstructive CAD. To date, the prognostic implications of nonobstructive CAD and the potential benefit of directing therapy based on nonobstructive CAD have not been carefully examined. A total of 27 125 consecutive patients who underwent computed tomographic angiography (12 enrolling centers and 6 countries) were prospectively entered into the COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter (CONFIRM) registry. Patients, without history of previous CAD or obstructive CAD, for whom baseline statin and aspirin use was available were analyzed. Each coronary segment was classified as normal or nonobstructive CAD (1%-49% stenosis). Patients were followed up for a median of 27.2 months for all-cause mortality. The study comprised 10 418 patients (5712 normal and 4706 with nonobstructive CAD). In multivariable analyses, patients with nonobstructive CAD had a 6% (95% confidence interval, 1%-12%) higher risk of mortality for each additional segment with nonobstructive plaque (P=0.021). Baseline statin use was associated with a reduced risk of mortality (hazard ratio, 0.44; 95% confidence interval, 0.28-0.68; P=0.0003), a benefit that was present for individuals with nonobstructive CAD (hazard ratio, 0.32; 95% confidence interval, 0.19-0.55; P<0.001) but not for those without plaque (hazard ratio, 0.66; 95% confidence interval, 0.30-1.43; P=0.287). When stratified by National Cholesterol Education Program/Adult Treatment Program III, no mortality benefit was observed in individuals without plaque. Aspirin use was not associated with mortality benefit, irrespective of the status of plaque.

CONCLUSIONS

The presence and extent of nonobstructive CAD predicted mortality. Baseline statin therapy was associated with a significant reduction in mortality for individuals with nonobstructive CAD but not for individuals without CAD.

CLINICAL TRIAL REGISTRATION

URL: http://clinicaltrials.gov/. Unique identifier NCT01443637.

Authors+Show Affiliations

From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.).From the Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada (B.J.W.C., G.S., Y.Y., L.C., R.M.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, Henry Ford Hospital, Wayne State University, Detroit, MI (M.A.-M.); Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B., V.Y.C., T.L.); Department of Medicine, Harbor University of California, Los Angeles Medical Center (M.J.B.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C., E.M.); Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (F.C., E.M.); Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, Korea (H.-J.C.); William Beaumont Hospital, Royal Oaks, MI (K.C.); Baptist Cardiac and Vascular Institute, Miami, FL (R.C.); Capitol Cardiology Associates, Albany, NY (A.D.); Department of Public Health (A.D.), Medicine and Radiology (F.L.), and Department of Radiology (J.K.M.), New York Presbyterian Hospital and the Weill Cornell Medical College; Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria (G.F.); Division of Cardiology, Technische Universität München, Munich, Germany (M.H., J.H.); Cardiovascular Medical Group, Los Angeles, CA (R.P.K.); Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Seoul National University Hospital, Seoul, South Korea (Y.-J.K.); Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.L.); Department of Cardiology, William Beaumont Hospital, Royal Oaks, MI (G.L.R.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (L.J.S.); and Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.). jkm2001@med.cornell.edu.No affiliation info available

Pub Type(s)

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

Language

eng

PubMed ID

25676000

Citation

Chow, Benjamin J W., et al. "Prognostic and Therapeutic Implications of Statin and Aspirin Therapy in Individuals With Nonobstructive Coronary Artery Disease: Results From the CONFIRM (COronary CT Angiography EvaluatioN for Clinical Outcomes: an InteRnational Multicenter Registry) Registry." Arteriosclerosis, Thrombosis, and Vascular Biology, vol. 35, no. 4, 2015, pp. 981-9.
Chow BJ, Small G, Yam Y, et al. Prognostic and therapeutic implications of statin and aspirin therapy in individuals with nonobstructive coronary artery disease: results from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter registry) registry. Arterioscler Thromb Vasc Biol. 2015;35(4):981-9.
Chow, B. J., Small, G., Yam, Y., Chen, L., McPherson, R., Achenbach, S., Al-Mallah, M., Berman, D. S., Budoff, M. J., Cademartiri, F., Callister, T. Q., Chang, H. J., Cheng, V. Y., Chinnaiyan, K., Cury, R., Delago, A., Dunning, A., Feuchtner, G., Hadamitzky, M., ... Min, J. K. (2015). Prognostic and therapeutic implications of statin and aspirin therapy in individuals with nonobstructive coronary artery disease: results from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter registry) registry. Arteriosclerosis, Thrombosis, and Vascular Biology, 35(4), 981-9. https://doi.org/10.1161/ATVBAHA.114.304351
Chow BJ, et al. Prognostic and Therapeutic Implications of Statin and Aspirin Therapy in Individuals With Nonobstructive Coronary Artery Disease: Results From the CONFIRM (COronary CT Angiography EvaluatioN for Clinical Outcomes: an InteRnational Multicenter Registry) Registry. Arterioscler Thromb Vasc Biol. 2015;35(4):981-9. PubMed PMID: 25676000.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Prognostic and therapeutic implications of statin and aspirin therapy in individuals with nonobstructive coronary artery disease: results from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter registry) registry. AU - Chow,Benjamin J W, AU - Small,Gary, AU - Yam,Yeung, AU - Chen,Li, AU - McPherson,Ruth, AU - Achenbach,Stephan, AU - Al-Mallah,Mouaz, AU - Berman,Daniel S, AU - Budoff,Matthew J, AU - Cademartiri,Filippo, AU - Callister,Tracy Q, AU - Chang,Hyuk-Jae, AU - Cheng,Victor Y, AU - Chinnaiyan,Kavitha, AU - Cury,Ricardo, AU - Delago,Augustin, AU - Dunning,Allison, AU - Feuchtner,Gundrun, AU - Hadamitzky,Martin, AU - Hausleiter,Jörg, AU - Karlsberg,Ronald P, AU - Kaufmann,Philipp A, AU - Kim,Yong-Jin, AU - Leipsic,Jonathon, AU - LaBounty,Troy, AU - Lin,Fay, AU - Maffei,Erica, AU - Raff,Gilbert L, AU - Shaw,Leslee J, AU - Villines,Todd C, AU - Min,James K, AU - ,, Y1 - 2015/02/12/ PY - 2015/2/14/entrez PY - 2015/2/14/pubmed PY - 2015/6/3/medline KW - aspirin KW - coronary angiography KW - coronary atherosclerosis KW - mortality KW - prognosis KW - statin SP - 981 EP - 9 JF - Arteriosclerosis, thrombosis, and vascular biology JO - Arterioscler Thromb Vasc Biol VL - 35 IS - 4 N2 - OBJECTIVE: We sought to examine the risk of mortality associated with nonobstructive coronary artery disease (CAD) and to determine the impact of baseline statin and aspirin use on mortality. APPROACH AND RESULTS: Coronary computed tomographic angiography permits direct visualization of nonobstructive CAD. To date, the prognostic implications of nonobstructive CAD and the potential benefit of directing therapy based on nonobstructive CAD have not been carefully examined. A total of 27 125 consecutive patients who underwent computed tomographic angiography (12 enrolling centers and 6 countries) were prospectively entered into the COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter (CONFIRM) registry. Patients, without history of previous CAD or obstructive CAD, for whom baseline statin and aspirin use was available were analyzed. Each coronary segment was classified as normal or nonobstructive CAD (1%-49% stenosis). Patients were followed up for a median of 27.2 months for all-cause mortality. The study comprised 10 418 patients (5712 normal and 4706 with nonobstructive CAD). In multivariable analyses, patients with nonobstructive CAD had a 6% (95% confidence interval, 1%-12%) higher risk of mortality for each additional segment with nonobstructive plaque (P=0.021). Baseline statin use was associated with a reduced risk of mortality (hazard ratio, 0.44; 95% confidence interval, 0.28-0.68; P=0.0003), a benefit that was present for individuals with nonobstructive CAD (hazard ratio, 0.32; 95% confidence interval, 0.19-0.55; P<0.001) but not for those without plaque (hazard ratio, 0.66; 95% confidence interval, 0.30-1.43; P=0.287). When stratified by National Cholesterol Education Program/Adult Treatment Program III, no mortality benefit was observed in individuals without plaque. Aspirin use was not associated with mortality benefit, irrespective of the status of plaque. CONCLUSIONS: The presence and extent of nonobstructive CAD predicted mortality. Baseline statin therapy was associated with a significant reduction in mortality for individuals with nonobstructive CAD but not for individuals without CAD. CLINICAL TRIAL REGISTRATION: URL: http://clinicaltrials.gov/. Unique identifier NCT01443637. SN - 1524-4636 UR - https://www.unboundmedicine.com/medline/citation/25676000/Prognostic_and_therapeutic_implications_of_statin_and_aspirin_therapy_in_individuals_with_nonobstructive_coronary_artery_disease:_results_from_the_CONFIRM__COronary_CT_Angiography_EvaluatioN_For_Clinical_Outcomes:_An_InteRnational_Multicenter_registry__registry_ L2 - https://www.ahajournals.org/doi/10.1161/ATVBAHA.114.304351?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -