Prognostic Value of CT Coronary Angiography In a Large Population with Known or Suspected CAD (original) (raw)
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Insights into Imaging, 2010
Aim To assess the prognostic relevance of 64-slice computed tomography coronary angiography (CT-CA) and symptoms in diabetics and non-diabetics referred for cardiac evaluation. Methods We followed 210 patients with diabetes type 2 (DM) and 203 non-diabetic patients referred for CT-CA for ruling out coronary artery disease (CAD). Patients were without known history of CAD and were divided into four categories on the basis of symptoms at presentation (none, atypical angina, typical angina and dyspnoea). Clinical end points were major cardiac events (MACE): cardiac-related death, non-fatal myocardial infarction, unstable angina and cardiac revascularizations. Cox proportional hazard models, with and without adjustment for risk factors and multiplicative interaction term (obstructive CAD × DM), were developed to predict outcome. Results DM patients with dyspnoea or who were asymptomatic showed a higher prevalence of obstructive CAD than non-diabetics (p ≤ 0.01). At mean follow-up of 20.4 months, DM patients had worse cardiac event-free survival in comparison with non-DM patients (90% vs. 81%, p=0.02). In multivariate analysis, CT-CA evidence of obstructive CAD (in DM patients: HR: 6.4; 95% CI: 2.3-17.5; p<0.001; in non-DM patients: HR: 7.4; 95% CI: 2.1-26.7; p=0.002) and the presence of typical angina (in DM patients: HR: 2.9; 95% CI: 1.3-6.3; p=0.007; in non-DM patients: HR: 2.7; 95% CI: 1.1-7.1; p=0.03) were independent predictors of MACE in both groups. Furthermore, other independent outcome predictors included dyspnoea (HR: 3.8; 95% CI: 1.7-8.5; p=0.001), the number of segments with any CAD (HR: 1.1; 95% CI: 1.001-1.2; p=0.04) in DM patients and coronary calcium score >100 in non-DM patients (HR: 5.6; 95% CI: 1.4-21.5; p = 0.01). In Cox regression analysis of the overall population, interaction term obstructive CAD × DM resulted in non-significance. Conclusions Among DM patients, dyspnoea carried a high event risk with a MACE rate four times higher. CT-CA findings were strongly predictive of outcome and proved valuable for further risk stratification.
The American Journal of Cardiology, 2011
It was previously reported that event-free survival rates of symptomatic patients with coronary artery disease (CAD) diagnosed by computed tomographic angiography decreased incrementally from normal coronary arteries to obstructive CAD. The aim of this study was to investigate the clinical outcomes of symptomatic patients with nonobstructive CAD with luminal stenoses of 1% to 49% on the basis of coronary plaque morphology in an outpatient setting. Among 3,499 consecutive symptomatic subjects who underwent computed tomographic angiography, 1,102 subjects with nonobstructive CAD (mean age 59 ؎ 14 years, 69.9% men) were prospectively followed for a mean of 78 ؎ 12 months. Coronary plaques were defined as noncalcified, mixed, and calcified per patient. Multivariate Cox proportional-hazards models were developed to predict all-cause mortality. The death rate of patients with nonobstructive CAD was 3.1% (34 deaths). The death rate increased incrementally from calcified plaque (1.4%) to mixed plaque (3.3%) to noncalcified plaque (9.6%), as well as from single-to triple-vessel disease (p <0.001). In subjects with mixed or calcified plaques, the death rate increased with the severity of coronary artery calcium from 1 to 9 to >400. The risk-adjusted hazard ratios of all-cause mortality in patients with nonobstructive CAD were 3.2 (95% confidence interval 1.3 to 8.0, p ؍ 0.001) for mixed plaques and 7.4 (95% confidence interval 2.7 to 20.1, p ؍ 0.0001) for noncalcified plaques compared with calcified plaques. The areas under the receiver-operating characteristic curve to predict all-cause mortality were 0.75 for mixed and 0.86 for noncalcified coronary lesions. In conclusion, this study demonstrates that the presence of noncalcified and mixed coronary plaques provided incremental value in predicting all-cause mortality in symptomatic subjects with nonobstructive CAD independent of age, gender, and conventional risk factors.
European Radiology, 2009
Purpose. The authors sought to determine the prognostic value of computed tomography coronary angiography (CTCA) in patients with acute chest pain (ACP). Materials and methods. A total of 145 consecutive patients (75 men; 64±12 years) with ACP were referred from the Emergency Department for CTCA, which was performed with a standard protocol using a 64-slice scanner. Patients were stratifi ed according to the Morise clinical score (low, intermediate, high) and to the CTCA fi ndings [absence of coronary artery disease (CAD), nonobstructive CAD, obstructive CAD]. Patients were followed up for the occurrence of major events: cardiac death, nonfatal myocardial infarction, unstable angina and revascularisation. Results. One hundred and twenty-seven (87.6%) patients were without a history of CAD, and 18 (12.4%) patients had a history of CAD. Obstructive CAD (>50% luminal narrowing) was detected in 35 (24%) patients; nonobstructive CAD (≤50% luminal narrowing) in 62 (43%) and absence of CAD in 48 (33%) patients. During a mean follow-up of 20±3 months, 20 events occurred (four hard events). Sixteen events (three hard events) occurred in patients without a history of CAD, and four events (one hard event) occurred in patients with a history of CAD. In patients with absence of CAD as detected by CTCA, the Riassunto Obiettivo. Scopo di questo lavoro è valutare il valore prognostico della angiografi a coronarica mediante tomografi a computerizzata (CTCA) in pazienti con dolore toracico acuto (ACP). Materiali e metodi. Centoquarantacinque pazienti (75 maschi; 64±12 anni) consecutivi con ACP sono stati inviati a CTCA dal dipartimento di emergenza. La CTCA è stata effettuata con tecnica standard ed uno scanner a 64 strati. I pazienti sono stati stratifi cati secondo lo score di Morise (basso, intermedio, alto) e la CTCA (assenza di coronary artery disease [CAD], CAD non ostruttiva, CAD ostruttiva). I pazienti sono stati seguiti per l'occorrenza di eventi maggiori: morte cardiaca, infarto miocardico non fatale, angina instabile e rivascolarizzazione. Risultati. Centoventisette (87,6%) pazienti non avevano storia di CAD e 18 (12,4%) pazienti avevano storia di CAD. È stata rilevata CAD ostruttiva (riduzione del lume >50%) in 35 (24%) pazienti; CAD non ostruttiva (riduzione del lume ≤50%) in 62 (43%) pazienti e assenza di CAD in 48 (33%) pazienti. Durante un follow-up medio di 20±3 mesi, abbiamo riscontrato 20 eventi (4 eventi hard). Sedici eventi (3 eventi hard) si sono verifi cati in pazienti senza storia di CAD e 4 eventi (1 evento hard) si è verifi cato nei pazienti con storia di CAD. Nei pazienti CARDIAC RADIOLOGY CARDIORADIOLOGIA
Diabetes Care, 2012
OBJECTIVE We examined the prevalence, extent, severity, and prognosis of coronary artery disease (CAD) in individuals with and without diabetes (DM) who are similar in CAD risk factors. RESEARCH DESIGN AND METHODS We identified 23,643 consecutive individuals without known CAD undergoing coronary computed tomography angiography. A total of 3,370 DM individuals were propensity matched in a 1-to-2 fashion to 6,740 unique non-DM individuals. CAD was defined as none, nonobstructive (1–49% stenosis), or obstructive (≥50% stenosis). All-cause mortality was assessed by risk-adjusted Cox proportional hazards models. RESULTS At a 2.2-year follow-up, 108 (3.2%) and 115 (1.7%) deaths occurred among DM and non-DM individuals, respectively. Compared with non-DM individuals, DM individuals possessed higher rates of obstructive CAD (37 vs. 27%) and lower rates of having normal arteries (28 vs. 36%) (P < 0.0001). CAD extent was higher for DM versus non-DM individuals for obstructive one-vessel di...
Journal of Cardiovascular Computed Tomography, 2009
Cardiac computed tomographic angiography (CTA) provides for accurate noninvasive diagnosis of coronary artery disease (CAD).We analyzed the clinical outcomes over 40 months in patients with and without CAD as determined by CTA in an outpatient setting.Consecutive symptomatic patients (n = 493; mean age, 58 ± 15 years; 70% men) with an intermediate likelihood of CAD referred for outpatient CTA evaluation were prospectively followed for a mean of 40 ± 9 months.Results of CTA included as normal (defined as normal coronary lumen), found in 32% (157), nonobstructive disease (<50% luminal stenosis) in 41% (204), obstructive disease (≥50% luminal stenosis) in 19% (93). Eight percent (n = 39) had ≥1 major nondiagnostic coronary artery segment. Follow-up identified 21 patients with myocardial infarction (MI) in the significant obstructive CAD and nondiagnostic group. No patients with either normal coronary arteries or nonobstructive disease experienced an MI during follow-up. The 40-month event-free survival was 100% for both the normal and nonobstructive disease groups, 97.5% for the nondiagnostic study group, and 79% for the group with obstructive CAD. After adjustment for age, sex, diabetes mellitus, hypertension, hypercholesterolemia, and baseline coronary artery calcium (CAC), a stepwise multivariable model (Cox regression) showed that obstructive CAD was an independent predictor of cardiac events and had significant incremental value over clinical risk factors and CAC (HR = 16.6; 95% CI, 4.9–55.2; P = 0.0001).In symptomatic patients with an intermediate likelihood of CAD referred for CTA, normal coronary arteries or nonobstructive CAD portends an excellent prognosis. The finding of obstructive CAD identifies patients at higher risk of subsequent MI, independent of cardiovascular risk factors and coronary artery calcium.
JAMA, 2014
IMPORTANCE Coronary artery disease (CAD) is a major cause of cardiovascular morbidity and mortality in patients with diabetes mellitus, yet CAD often is asymptomatic prior to myocardial infarction (MI) and coronary death. OBJECTIVE To assess whether routine screening for CAD by coronary computed tomography angiography (CCTA) in patients with type 1 or type 2 diabetes deemed to be at high cardiac risk followed by CCTA-directed therapy would reduce the risk of death and nonfatal coronary outcomes. DESIGN, SETTING, AND PARTICIPANTS The FACTOR-64 study was a randomized clinical trial in which 900 patients with type 1 or type 2 diabetes of at least 3 to 5 years' duration and without symptoms of CAD were recruited from 45 clinics and practices of a single health system (Intermountain Healthcare, Utah), enrolled at a single-site coordinating center, and randomly assigned to CAD screening with CCTA (n = 452) or to standard national guidelines-based optimal diabetes care (n = 448) (targets: glycated hemoglobin level <7.0%, low-density lipoprotein cholesterol level <100 mg/dL, systolic blood pressure <130 mm Hg). All CCTA imaging was performed at the coordinating center. Standard therapy or aggressive therapy (targets: glycated hemoglobin level <6.0%, low-density lipoprotein cholesterol level <70 mg/dL, high-density lipoprotein cholesterol level >50 mg/dL [women] or >40 mg/dL [men], triglycerides level <150 mg/dL, systolic blood pressure <120 mm Hg), or aggressive therapy with invasive coronary angiography, was recommended based on CCTA findings. Enrollment occurred between July 2007 and May 2013, and follow-up extended to August 2014. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of all-cause mortality, nonfatal MI, or unstable angina requiring hospitalization; the secondary outcome was ischemic major adverse cardiovascular events (composite of CAD death, nonfatal MI, or unstable angina). RESULTS At a mean follow-up time of 4.0 (SD, 1.7) years, the primary outcome event rates were not significantly different between the CCTA and the control groups (6.2% [28 events] vs 7.6% [34 events]; hazard ratio, 0.80 [95% CI, 0.49-1.32]; P = .38). The incidence of the composite secondary end point of ischemic major adverse cardiovascular events also did not differ between groups (4.4% [20 events] vs 3.8% [17 events]; hazard ratio, 1.15 [95% CI, 0.60-2.19]; P = .68). CONCLUSIONS AND RELEVANCE Among asymptomatic patients with type 1 or type 2 diabetes, use of CCTA to screen for CAD did not reduce the composite rate of all-cause mortality, nonfatal MI, or unstable angina requiring hospitalization at 4 years. These findings do not support CCTA screening in this population.