Superior Risk Stratification With Coronary Computed Tomography Angiography Using a Comprehensive Atherosclerotic Risk Score

• Authors: Alexander R. van Rosendael, Leiden University; Leslee Shaw, Emory University; Joe Xie, Emory University; Aukelien C. Dimitriu-Leen, Leiden University; Jeff M. Smit, Leiden University; Arthur J. Scholte, Leiden University; Jacob M. van Werkhoven, Leiden University; Tracey Q. Callister, Tennessee Heart & Vascular Institute; Augustin DeLago, Capitol Cardiology Associates
• Journal Title: JACC-CARDIOVASCULAR IMAGING
• Volume: Volume 12, Number 10
• Publisher: ELSEVIER SCIENCE INC | 2019-10-01, Pages 1987-1997
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.jcmg.2018.10.024
• Subjects: Health Sciences, Medicine and Surgery; Health Sciences, Radiology
• Keywords: Science & Technology; Life Sciences & Biomedicine; Cardiac & Cardiovascular Systems; Radiology, Nuclear Medicine & Medical Imaging; Cardiovascular System & Cardiology; coronary computed tomography angiography; risk stratification; stable coronary artery disease; PROGNOSTIC VALUE; ARTERY-DISEASE; CLINICAL-OUTCOMES; CAUSE MORTALITY; DIAGNOSTIC-ACCURACY; PREDICTION; REGISTRY; THERAPY

Abstract

Objectives: This study was designed to assess the prognostic value of a new comprehensive coronary computed tomography angiography (CTA) score compared with the stenosis severity component of the Coronary Artery Disease-Reporting and Data System (CAD-RADS). Background: Current risk assessment with coronary CTA is mainly focused on maximal stenosis severity. Integration of plaque extent, location, and composition in a comprehensive model may improve risk stratification. Methods: A total of 2,134 patients with suspected but without known CAD were included. The predictive value of the comprehensive CTA score (ranging from 0 to 42 and divided into 3 groups: 0 to 5, 6 to 20, and >20) was compared with the CAD-RADS combined into 3 groups (0% to 30%, 30% to 70% and ≥70% stenosis). Its predictive performance was internally and externally validated (using the 5-year follow-up dataset of the CONFIRM [Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry], n = 1,971). Results: The mean age of patients was 55 ± 13 years, mean follow-up 3.6 ± 2.8 years, and 130 events (myocardial infarction or death) occurred. The new, comprehensive CTA score showed strong and independent predictive value using the Cox proportional hazard analysis. A model including clinical variables plus comprehensive CTA score showed better discrimination of events compared with a model consisting of clinical variables plus CAD-RADS (0.768 vs. 0.742, p = 0.001). Also, the comprehensive CTA score correctly reclassified a significant proportion of patients compared with the CAD-RADS (net reclassification improvement 12.4%, p < 0.001). Good predictive accuracy was reproduced in the external validation cohort. Conclusions: The new comprehensive CTA score provides better discrimination and reclassification of events compared with the CAD-RADS score based on stenosis severity only. The score retained similar prognostic accuracy when externally validated. Anatomic risk scores can be improved with the addition of extent, location, and compositional measures of atherosclerotic plaque. (Comprehensive CTA risk score calculator is available at: http://18.224.14.19/calcApp/)