Incremental Prognostic Value of Cardiac Computed Tomography in Coronary Artery Disease Using CONFIRM

Abstract

on behalf/for the CONFIRM Investigators Background-Large multicenter studies validating the prognostic value of coronary computed tomographic angiography (CCTA) and left ventricular ejection fraction (LVEF) are lacking. We sought to confirm the independent and incremental prognostic value of coronary artery disease (CAD) severity measured using 64-slice CCTA over LVEF and clinical variables. Methods and Results-A large international multicenter registry (CONFIRM Registry) was queried, and CCTA patients with LVEF data on CCTA were screened. Patients with a history of myocardial infarction, coronary revascularization, or cardiac transplantation were excluded. The National Cholesterol Education Program-Adult Treatment Panel III risk was calculated for each patient, and CCTA was evaluated for CAD severity (normal, nonobstructive, non-high-risk, or high-risk CAD) and LVEF Ͻ50%. Patients were followed for an end point of all-cause mortality; 27 125 patients underwent CCTA at 12 participating centers, with a total of 14 064 patients meeting the analysis criteria. Follow-up was available for 13 966 (99.3%) patients (mean follow-up of 22.5 months; 95% confidence interval, 22.3 to 22.7 months). All-cause mortality (271 deaths) occurred in 0.65% of patients without coronary atherosclerosis, 1.99% of patients with nonobstructive CAD, 2.90% of patients with non-high-risk CAD, and 4.95% for patients with high-risk CAD. Multivariable analysis confirmed that LVEF Ͻ50% (hazard ratio, 2.74; 95% confidence interval, 2.12 to 3.51) and CAD severity (hazard ratio,1.58; 95% confidence interval, 1.42 to 1.76) were predictors of all-cause mortality, and CAD severity had incremental value over LVEF and clinical variables. Conclusions-Our results demonstrate that CCTA measures of CAD severity and LVEF have independent prognostic value. Incorporation of CAD severity provides incremental value for predicting all-cause death over routine clinical predictors and LVEF in patients with suspected obstructive CAD. (Circ Cardiovasc Imaging. 2011;4:463-472.)

Epidemiology of coronary heart disease and acute coronary syndrome

“…On the other hand, diabetes was confirmed by the Framingham Study as a risk factor for silent infarction in men but not in women (57). In men with diabetes, the fraction of MI that were unrecognized was more than two times higher than in those without (39% vs. 18%); in comparison, women with diabetes in this study (36) as well as in the Heart and Estrogen/progestin Replacement Study (HERS), were less likely to have unrecognized MI (57,69).…”

“…Despite lack of symptoms, the presence and extent of non-obstructive CHD are associated with a worse prognosis compared with patients with no evidence of CHD (35,36). In a retrospective cohort study of 37,674 USA veterans (96% male) without prior CHD events who underwent coronary angiography between October 2007 and September 2012 and were followed for one year, the risk of MI increased significantly and progressively in parallel with the extent of both non-obstructive (at least one stenosis ≥20% but <70%) and obstructive CHD (at least one stenosis ≥70%) (35).…”

2013 Esc Guidelines on the Management of Stable Coronary Artery Disease

“…Хотя в настоящее время отсутствуют проспектив-ные исследования с рандомизацией пациентов в группы с проведением КТА коронарных артерий или без нее и оценкой жестких клинических конеч-ных точек у пациентов со стабильными приступами боли в грудной клетке (так же, как и для других мето-дов визуализации), данные из регистров подтвер-ждают превосходный прогноз, если при КТА выявля-ется отсутствие стенозов коронарных артерий [165][166][167]. Показания к проведению КТА коронарных артерий суммарно приводятся на рисунке 2.…”

Cardiac imaging to investigate suspected cardiac pain in the post-treadmill era

“…19,20 Prognosis A CTCA scan negative for any coronary atheroma gives an extremely good prognosis (annual all-cause mortality rate of 0.6%) whereas those with high-risk obstructive disease have an annual event rate of 2.7%. 21 Patients with non-obstructive atheroma have an annual event rate of 1.1%; this incremental prognostic insight is of importance, with new evidence suggesting that those with even a low clinical risk of major adverse cardiac events may benefi t from statin therapy. 22,23 Future prospects…”