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The Coronary Artery Disease-Reporting and Data System (CAD-RADS): Prognostic and Clinical Implications Associated With Standardized Coronary Computed Tomography Angiography Reporting.
JACC Cardiovasc Imaging. 2018 01; 11(1):78-89.JC

Abstract

OBJECTIVES

This study sought to assess clinical outcomes associated with the novel Coronary Artery Disease-Reporting and Data System (CAD-RADS) scores used to standardize coronary computed tomography angiography (CTA) reporting and their potential utility in guiding post-coronary CTA care.

BACKGROUND

Clinical decision support is a major focus of health care policies aimed at improving guideline-directed care. Recently, CAD-RADS was developed to standardize coronary CTA reporting and includes clinical recommendations to facilitate patient management after coronary CTA.

METHODS

In the multinational CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry, 5,039 patients without known coronary artery disease (CAD) underwent coronary CTA and were stratified by CAD-RADS scores, which rank CAD stenosis severity as 0 (0%), 1 (1% to 24%), 2 (25% to 49%), 3 (50% to 69%), 4A (70% to 99% in 1 to 2 vessels), 4B (70% to 99% in 3 vessels or ≥50% left main), or 5 (100%). Kaplan-Meier and multivariable Cox models were used to estimate all-cause mortality or myocardial infarction (MI). Receiver-operating characteristic (ROC) curves were used to compare CAD-RADS to the Duke CAD Index and traditional CAD classification. Referrals to invasive coronary angiography (ICA) after coronary CTA were also assessed.

RESULTS

Cumulative 5-year event-free survival ranged from 95.2% to 69.3% for CAD-RADS 0 to 5 (p < 0.0001). Higher scores were associated with elevations in event risk (hazard ratio: 2.46 to 6.09; p < 0.0001). The ROC curve for prediction of death or MI was 0.7052 for CAD-RADS, which was noninferior to the Duke Index (0.7073; p = 0.893) and traditional CAD classification (0.7095; p = 0.783). ICA rates were 13% for CAD-RADS 0 to 2, 66% for CAD-RADS 3, and 84% for CAD-RADS ≥4A. For CAD-RADS 3, 58% of all catheterizations occurred within the first 30 days of follow-up. In a patient subset with available medication data, 57% of CAD-RADS 3 patients who received 30-day ICA were either asymptomatic or not receiving antianginal therapy at baseline, whereas only 32% had angina and were receiving medical therapy.

CONCLUSIONS

CAD-RADS effectively identified patients at risk for adverse events. Frequent ICA use was observed among patients without severe CAD, many of whom were asymptomatic or not taking antianginal drugs. Incorporating CAD-RADS into coronary CTA reports may provide a novel opportunity to promote evidence-based care post-coronary CTA.

Authors+Show Affiliations

Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.Division of Cardiology, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, Florida.Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California.Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California.Division of Cardiology, Harbor UCLA Medical Center, Los Angeles, California.Division of Cardiology, University of Erlangen, Erlangen, Germany.Division of Cardiology, Weill Cornell Medical College and the NewYork-Presbyterian Hospital, New York, New York.Division of Cardiology, Tennessee Heart and Vascular Institute, Hendersonville, Tennessee.Division of Cardiology, Hospital da Luz, Lisbon, Portugal.Division of Cardiology, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.Division of Cardiology, Henry Ford Hospital, Detroit, Michigan.Division of Cardiology, University of Milan, Centro Cardiologico Monzino, IRCCS Milan, Italy.Division of Cardiology, University of Milan, Centro Cardiologico Monzino, IRCCS Milan, Italy.Division of Cardiology, Department of Radiology/Centre de Recherche, Montreal Heart Institute/Universitè de Montreal, Montreal, Quebec, Canada.Division of Cardiology, Department of Radiology/Centre de Recherche, Montreal Heart Institute/Universitè de Montreal, Montreal, Quebec, Canada.Division of Cardiology, William Beaumont Hospital, Royal Oaks, Michigan.Division of Cardiology, William Beaumont Hospital, Royal Oaks, Michigan.Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany.Division of Cardiology, Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany.Division of Cardiology, Medical University of Innsbruck, Innsbruck, Austria.Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina.Division of Cardiology, Capitol Cardiology Associates, Albany, New York.Division of Cardiology, Seoul National University Hospital, Seoul, South Korea.Division of Cardiology, University Hospital, Zurich, Switzerland.Division of Cardiology, Walter Reed Medical Center, Washington, DC.Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.Division of Cardiology, Weill Cornell Medical College and the NewYork-Presbyterian Hospital, New York, New York.Division of Cardiology, Weill Cornell Medical College and the NewYork-Presbyterian Hospital, New York, New York.Division of Cardiology, Weill Cornell Medical College and the NewYork-Presbyterian Hospital, New York, New York.Division of Cardiology, Weill Cornell Medical College and the NewYork-Presbyterian Hospital, New York, New York.Division of Cardiology, Weill Cornell Medical College and the NewYork-Presbyterian Hospital, New York, New York.Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia. Electronic address: lshaw3@emory.edu.

Pub Type(s)

Comparative Study
Journal Article
Multicenter Study
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

29301713

Citation

Xie, Joe X., et al. "The Coronary Artery Disease-Reporting and Data System (CAD-RADS): Prognostic and Clinical Implications Associated With Standardized Coronary Computed Tomography Angiography Reporting." JACC. Cardiovascular Imaging, vol. 11, no. 1, 2018, pp. 78-89.
Xie JX, Cury RC, Leipsic J, et al. The Coronary Artery Disease-Reporting and Data System (CAD-RADS): Prognostic and Clinical Implications Associated With Standardized Coronary Computed Tomography Angiography Reporting. JACC Cardiovasc Imaging. 2018;11(1):78-89.
Xie, J. X., Cury, R. C., Leipsic, J., Crim, M. T., Berman, D. S., Gransar, H., Budoff, M. J., Achenbach, S., Ó Hartaigh, B., Callister, T. Q., Marques, H., Rubinshtein, R., Al-Mallah, M. H., Andreini, D., Pontone, G., Cademartiri, F., Maffei, E., Chinnaiyan, K., Raff, G., ... Shaw, L. J. (2018). The Coronary Artery Disease-Reporting and Data System (CAD-RADS): Prognostic and Clinical Implications Associated With Standardized Coronary Computed Tomography Angiography Reporting. JACC. Cardiovascular Imaging, 11(1), 78-89. https://doi.org/10.1016/j.jcmg.2017.08.026
Xie JX, et al. The Coronary Artery Disease-Reporting and Data System (CAD-RADS): Prognostic and Clinical Implications Associated With Standardized Coronary Computed Tomography Angiography Reporting. JACC Cardiovasc Imaging. 2018;11(1):78-89. PubMed PMID: 29301713.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The Coronary Artery Disease-Reporting and Data System (CAD-RADS): Prognostic and Clinical Implications Associated With Standardized Coronary Computed Tomography Angiography Reporting. AU - Xie,Joe X, AU - Cury,Ricardo C, AU - Leipsic,Jonathon, AU - Crim,Matthew T, AU - Berman,Daniel S, AU - Gransar,Heidi, AU - Budoff,Matthew J, AU - Achenbach,Stephan, AU - Ó Hartaigh,Bríain, AU - Callister,Tracy Q, AU - Marques,Hugo, AU - Rubinshtein,Ronen, AU - Al-Mallah,Mouaz H, AU - Andreini,Daniele, AU - Pontone,Gianluca, AU - Cademartiri,Filippo, AU - Maffei,Erica, AU - Chinnaiyan,Kavitha, AU - Raff,Gilbert, AU - Hadamitzky,Martin, AU - Hausleiter,Joerg, AU - Feuchtner,Gudrun, AU - Dunning,Allison, AU - DeLago,Augustin, AU - Kim,Yong-Jin, AU - Kaufmann,Philipp A, AU - Villines,Todd C, AU - Chow,Benjamin J W, AU - Hindoyan,Niree, AU - Gomez,Millie, AU - Lin,Fay Y, AU - Jones,Erica, AU - Min,James K, AU - Shaw,Leslee J, PY - 2017/01/19/received PY - 2017/08/24/revised PY - 2017/08/24/accepted PY - 2018/1/6/entrez PY - 2018/1/6/pubmed PY - 2019/10/18/medline KW - appropriate use KW - clinical decision support KW - coronary computed tomography angiography KW - prognosis SP - 78 EP - 89 JF - JACC. Cardiovascular imaging JO - JACC Cardiovasc Imaging VL - 11 IS - 1 N2 - OBJECTIVES: This study sought to assess clinical outcomes associated with the novel Coronary Artery Disease-Reporting and Data System (CAD-RADS) scores used to standardize coronary computed tomography angiography (CTA) reporting and their potential utility in guiding post-coronary CTA care. BACKGROUND: Clinical decision support is a major focus of health care policies aimed at improving guideline-directed care. Recently, CAD-RADS was developed to standardize coronary CTA reporting and includes clinical recommendations to facilitate patient management after coronary CTA. METHODS: In the multinational CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry, 5,039 patients without known coronary artery disease (CAD) underwent coronary CTA and were stratified by CAD-RADS scores, which rank CAD stenosis severity as 0 (0%), 1 (1% to 24%), 2 (25% to 49%), 3 (50% to 69%), 4A (70% to 99% in 1 to 2 vessels), 4B (70% to 99% in 3 vessels or ≥50% left main), or 5 (100%). Kaplan-Meier and multivariable Cox models were used to estimate all-cause mortality or myocardial infarction (MI). Receiver-operating characteristic (ROC) curves were used to compare CAD-RADS to the Duke CAD Index and traditional CAD classification. Referrals to invasive coronary angiography (ICA) after coronary CTA were also assessed. RESULTS: Cumulative 5-year event-free survival ranged from 95.2% to 69.3% for CAD-RADS 0 to 5 (p < 0.0001). Higher scores were associated with elevations in event risk (hazard ratio: 2.46 to 6.09; p < 0.0001). The ROC curve for prediction of death or MI was 0.7052 for CAD-RADS, which was noninferior to the Duke Index (0.7073; p = 0.893) and traditional CAD classification (0.7095; p = 0.783). ICA rates were 13% for CAD-RADS 0 to 2, 66% for CAD-RADS 3, and 84% for CAD-RADS ≥4A. For CAD-RADS 3, 58% of all catheterizations occurred within the first 30 days of follow-up. In a patient subset with available medication data, 57% of CAD-RADS 3 patients who received 30-day ICA were either asymptomatic or not receiving antianginal therapy at baseline, whereas only 32% had angina and were receiving medical therapy. CONCLUSIONS: CAD-RADS effectively identified patients at risk for adverse events. Frequent ICA use was observed among patients without severe CAD, many of whom were asymptomatic or not taking antianginal drugs. Incorporating CAD-RADS into coronary CTA reports may provide a novel opportunity to promote evidence-based care post-coronary CTA. SN - 1876-7591 UR - https://www.unboundmedicine.com/medline/citation/29301713/The_Coronary_Artery_Disease_Reporting_and_Data_System__CAD_RADS_:_Prognostic_and_Clinical_Implications_Associated_With_Standardized_Coronary_Computed_Tomography_Angiography_Reporting_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S1936-878X(17)30914-2 DB - PRIME DP - Unbound Medicine ER -