Prognostic Value of Multidetector Coronary Computed Tomographic Angiography for Prediction of All-Cause Mortality James K. Min, Leslee J. Shaw, Richard B. Devereux, Peter M. Okin, Jonathan W. ...Weinsaft, Donald J. Russo, Nicholas J. Lippolis, Daniel S. Berman, Tracy Q. Callister This study examined the prediction of death from all-causes by the results of coronary computed tomographic angiography (CCTA). The CCTA measurements predictive of death included severity of stenosis in the proximal left anterior descending artery (p = 0.001) and the extent of coronary artery disease (CAD) by the number of vessels with ≥50% stenosis (p < 0.0001) and ≥70% stenosis (p < 0.0001). A modified Duke prognostic CAD index, a previously validated angiographic score integrating proximal disease, disease extent, and left main disease, improved stratification of death (p < 0.0001). In patients presenting with chest pain, CCTA identifies individuals at increased risk for all-cause death. Importantly, a negative CCTA portends an extremely low risk for death.
Coronary Artery Calcium to Predict All-Cause Mortality in Elderly Men and Women Paolo Raggi, Maria C. Gongora, Ambarish Gopal, Tracy Q. Callister, Matthew Budoff, Leslee J. Shaw A total of 35,388 ...patients were followed for a mean of 5.8 ± 3 years after coronary artery calcium (CAC) screening. The primary end point of all-cause mortality was assessed in men and women spanning in age from <40 to >80 years. Overall mortality increased with each age decile with a relative hazard of 1.09 (95% confidence interval CI: 1.08 to 1.10, p < 0.0001) and rates were greater for men than women (hazard ratio: 1.53, 95% CI: 1.32 to 1.77, p < 0.0001). Increasing CAC scores were associated with decreasing survival across all age deciles (p < 0.0001). The use of CAC allowed us to reclassify risk in ∼40% of patients >70 years who were believed to be at high-risk according to traditional risk factor assessment.
Although family history (FH) of coronary artery disease (CAD) is considered a risk factor for future cardiovascular events, the prevalence, extent, severity, and prognosis of young patients with FH ...of CAD have been inadequately studied. From 27,125 consecutive patients who underwent coronary computed tomographic angiography, 6,308 young patients (men aged <55 years and women aged <65 years) without known CAD were identified. Obstructive CAD was defined as >50% stenosis in a coronary artery >2 mm diameter. Risk-adjusted logistic regression, Kaplan-Meier, and Cox proportional-hazards models were used to compare patients with and without FH of CAD. Compared with subjects without FH of CAD, those with FH of CAD (FH+) had higher prevalences of any CAD (40% vs 30%, p <0.001) and obstructive CAD (11% vs 7%, p <0.001), with multivariate odds of FH+ increasing the likelihood of obstructive CAD by 71% (p <0.001). After a mean follow-up period of 2 ± 1 years (42 myocardial infarctions and 39 all-cause deaths), FH+ patients experienced higher annual rates of myocardial infarction (0.5% vs 0.2%, log-rank p = 0.001), with a positive FH the strongest predictor of myocardial infarction (hazard ratio 2.6, 95% confidence interval 1.4 to 4.8, p = 0.002). In conclusion, young FH+ patients have higher presence, extent, and severity of CAD, which are associated with increased risk for myocardial infarction. Compared with other clinical CAD risk factors, positive FH in young patients is the strongest clinical predictor of future unheralded myocardial infarction.
Objectives The aim of this study was to further explore the interplay between smoking status, coronary artery calcium (CAC), and all-cause mortality. Background Prior studies have not directly ...compared the relative prognostic impact of CAC in smokers versus nonsmokers. In particular, although a calcium score of zero (CAC = 0) is a known favorable prognostic marker, whether smokers with CAC = 0 have as good a prognosis as nonsmokers with CAC = 0 is unknown. Given that computed tomography (CT) screening for lung cancer appears effective in smokers, the relative prognostic implications of visualizing any CAC versus no CAC on such screening also deserve study. Methods Our study cohort consisted of 44,042 asymptomatic individuals referred for noncontrast cardiac CT (age 54 ± 11 years, 54% men). Subjects were followed for a mean of 5.6 years. The primary endpoint was all-cause mortality. Results Approximately 14% (n = 6,020) of subjects were active smokers at enrollment. There were 901 deaths (2.05%) overall, with increased mortality in smokers versus nonsmokers (4.3% vs. 1.7%, p < 0.0001). Smoking remained a risk factor for mortality across increasing strata of CAC scores (1 to 100, 101 to 400, and >400). At each stratum of elevated CAC score, mortality in smokers was consistently higher than mortality in nonsmokers from the CAC stratum above. In multivariable analysis within these strata, we found mortality hazard ratios of 3.8 (95% confidence interval CI: 2.8 to 5.2), 3.5 (95% CI: 2.6 to 4.9), and 2.7 (95% CI: 2.1 to 3.5), respectively, in smokers compared with nonsmokers. However, among the 19,898 individuals with CAC = 0, the mortality hazard ratio for smokers without CAC was 3.6 (95% CI: 2.3 to 5.7), compared with nonsmokers without CAC. Conclusions Smoking is a risk factor for death across the entire spectrum of subclinical coronary atherosclerosis. Smokers with any CAC had significantly higher mortality than smokers without CAC, a finding with implications for smokers undergoing lung cancer CT-based screening. However, the absence of CAC might not be as useful a “negative risk factor” in active smokers, because this group has mortality rates similar to nonsmokers with mild-to-moderate atherosclerosis.
Background Clinical outcomes and resource utilization after coronary computed tomography angiography (CTA) versus myocardial perfusion single-photon emission CT (MPS) in patients with stable angina ...and suspected coronary artery disease (CAD) has not been examined. Objective We determined the near-term clinical effect and resource utilization after cardiac CTA compared with MPS. Methods We randomly assigned 180 patients (age, 57.3 ± 9.8 years; 50.6% men) presenting with stable chest pain and suspected CAD at 2 sites to initial diagnostic evaluation by coronary CTA (n = 91) or MPS (n = 89). The primary outcome was near-term angina-specific health status; the secondary outcomes were incident medical and invasive treatments for CAD, CAD health care costs, and estimated radiation dose. Results No patients experienced myocardial infarction or death with 98.3% follow-up at 55 ± 34 days. Both arms experienced comparable improvements in angina-specific health status. Patients who received coronary CTA had increased incident aspirin (22% vs 8%; P = 0.04) and statin (7% vs −3.5%; P = 0.03) use, similar rates of CAD-related hospitalization, invasive coronary angiography, noninvasive cardiac imaging tests, and increased revascularization (8% vs 1%; P = 0.03). Coronary CTA had significantly lower total costs ($781.08 interquartile range (IQR), $367.80–$4349.48 vs $1214.58 IQR, $978.02–$1569.40; P < 0.001) with no difference in induced costs. Coronary CTA had a significantly lower total estimated effective radiation dose (7.4 mSv IQR, 5.0–14.0 mSv vs 13.3 mSv IQR, 13.1–38.0 mSv; P < 0.0001) with no difference in induced radiation. Conclusion In a pilot randomized controlled trial, patients with stable CAD undergoing coronary CTA and MPS experience comparable improvements in near-term angina-related quality of life. Compared with MPS, coronary CTA evaluation is associated with more aggressive medical therapy, increased coronary revascularization, lower total costs, and lower effective radiation dose.
Objectives We sought to determine the incremental prognostic value of 64 multi-slice coronary computed tomography angiography (CCTA) in coronary artery bypass graft (CABG) patients. Background ...Prognostication in CABG patients can be difficult. Anatomical assessment of native coronary artery disease and graft patency might provide useful information, but the utility of CCTA in the assessment of CABG patients is unknown. Methods Six hundred fifty-seven CABG patients with all-cause mortality follow-up were identified from a multicenter CCTA registry, of 10,628 patients from 5 CCTA centers. Clinical risk was profiled with modified logistic and additive EuroSCOREs (European Systems for Cardiac Operative Risk Evaluations). The CCTA defined coronary anatomy. Patients were classified by unprotected coronary territory (UCT) or a summary of native vessel disease and graft patency: the coronary artery protection score (CAPS). Results Forty-four deaths occurred during a mean follow-up of 20 months. Left ventricular ejection fraction, creatinine, age, severity of native vessel disease, UCT, CAPS, and EuroSCOREs were univariate predictors of mortality (p &amp;amp;lt; 0.001). In multivariate analysis with additive EuroSCORE, UCT (p = 0.004) and CAPS were predictive of events (p &amp;amp;lt; 0.001). In comparison with additive EuroSCORE, CAPS score was associated with a 27% net reclassification index. Conclusions Coronary computed tomography angiography provides incremental anatomical data to clinical risk assessment to help determine the prognosis of patients after CABG. The CAPS evaluation with CCTA might help identify those patients at highest risk.
Background Dilatation of the aortic root and other segments of the thoracic aorta is important in the pathogenesis of aortic regurgitation and of aortic dissection. Although echocardiographic ...criteria exist to detect aortic root dilation, comparably standardized methods have not been developed to detect enlargement of the remainder of the thoracic aorta. Nongated axial chest computed tomography (CT), traditionally used to evaluate aortic size, does not account for the obliquity, systolic expansion, and nonaxial motion of the aorta during the cardiac cycle. Reference values for aortic diameters in anatomically correct double-oblique short axis images have not been established with the use of electrocardiogram (ECG)-gated 64-detector row multidetector CT (MDCT). Objectives To establish reference values for thoracic aortic diameters MDCT in healthy normotensive nonobese adults without evident cardiovascular disease. Methods A total of 103 (43% women, age 51 ± 14 years) consecutive normotensive, nonobese adults free of cardiac or aortic structural disease or arrhythmia underwent MDCT examination to determine aortic dimensions. Results End-diastolic diameter 95% confidence intervals were 2.5–3.7 cm for the aortic root, 2.1–3.5 cm for the ascending aorta, and 1.7–2.6 cm for the descending thoracic aorta. Aortic diameters were significantly greater at end systole than end diastole (mean difference 1.9 ± 1.2 mm for ascending and 1.3 ± 1.8 for descending thoracic aorta, P < 0.001). Aortic root and ascending aortic diameter increased significantly with age and body surface area. Conclusions This study establishes age- and sex-specific ECG-gated MDCT reference values for thoracic aortic diameters in healthy, normotensive, nonobese adults to identify aortic pathology by MDCT. MDCT measurements of the thoracic aorta should use ECG-gated double-oblique short-axis images for accurate quantification.
Abstract Background Risk assessment in the extensive calcified plaque phenotype has been limited by small sample size. Objective We studied all-cause mortality rates among asymptomatic patients with ...markedly elevated Agatston scores > 1000. Methods We studied a clinical cohort of 44,052 asymptomatic patients referred for coronary calcium scans. Mean follow-up was 5.6 years (range, 1–13 years). All-cause mortality rates were calculated after stratifying by Agatston score (0, 1–1000, 1001–1500, 1500–2000, and >2000). A multivariable Cox regression model adjusting for self-reported traditional risk factors was created to assess the relative mortality hazard of Agatston scores 1001 to 1500, 1501 to 2000, and >2000. With the use of post-estimation modeling, we assessed for the presence of an upper threshold of risk with high Agatston scores. Results A total of 1593 patients (4% of total population) had Agatston score > 1000. There was a continuous graded decrease in estimated 10-year survival across increasing Agatston score, continuing when Agatston score > 1000 (Agatston score 1001–1500, 78%; Agatston score 1501–2000, 74%; Agatston score > 2000, 51%). After multivariable adjustment, Agatston scores 1001 to 1500, 1501 to 2000, and >2000 were associated with an 8.05-, 7.45-, and 13.26-fold greater mortality risk, respectively, than for Agatston score of 0. Compared with Agatston score 1001 to 1500, Agatston score 1501 to 2000 had a similar all-cause mortality risk, whereas Agatston score > 2000 had an increased relative risk (Agatston score 1501–2000: hazard ratio HR, 1.01 95% CI, 0.67–1.51; Agatston score > 2000: HR, 1.79 95% CI, 1.30–2.46). Graphical assessment of the predicted survival model suggests no upper threshold for risk associated with calcified plaque in coronary arteries. Conclusion Increasing calcified plaque in coronary arteries continues to predict a graded decrease in survival among patients with extensive Agatston score > 1000 with no apparent upper threshold.
Patients with chronic kidney disease have a worse cardiovascular prognosis than those without. The aim of this study was to determine the incremental prognostic value of coronary computed tomographic ...angiography in predicting mortality across the entire spectrum of renal function in patients with known or suspected coronary artery disease (CAD). A large international multicenter registry was queried, and patients with left ventricular ejection fraction (LVEF) and creatinine data were screened. National Cholesterol Education Program Adult Treatment Panel III risk was calculated. Coronary computed tomographic angiographic results were evaluated for CAD severity (normal, nonobstructive, or obstructive) and an LVEF <50%. Patients were followed for the end point of all-cause mortality. Among 5,655 patients meeting the study criteria, follow-up was available for 5,572 (98.9%; median follow-up duration 18.6 months). All-cause mortality (66 deaths) significantly increased with every 10-unit decrease in renal function (hazard ratio HR 1.23, 95% confidence interval CI 1.07 to 1.41). All-cause mortality occurred in 0.33% of patients without coronary atherosclerosis, 1.82% of patients with nonobstructive CAD, and 2.43% of patients with obstructive CAD. Multivariate Cox proportional-hazards models revealed that impaired renal function (HR 2.29, 95% CI 1.65 to 3.18), CAD severity (HR 1.81, 95% CI 1.31 to 2.51), and an abnormal LVEF (HR 4.16, 95% CI 2.45 to 7.08) were independent predictors of all-cause mortality. In conclusion, coronary computed tomographic angiographic measures of CAD severity and the LVEF provide effective risk stratification across a wide spectrum of renal function. Furthermore, renal dysfunction, CAD severity, and the LVEF have additive value for predicting all-cause death in patients with suspected obstructive CAD.
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