Prevalence and Severity of Coronary Artery Disease and Adverse Events Among Symptomatic Patients With Coronary Artery Calcification Scores of Zero Undergoing Coronary Computed Tomography Angiography

Q: What are the key findings of this study?

In symptomatic patients with a CAC score of 0, obstructive CAD on CCTA increased the risk of mortality, MI, or late revascularization compared to no obstructive CAD (HR 5.7; 95% CI 2.5-13.1).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Symptomatic patients undergoing CCTA (n=10037). Intervention: Obstructive CAD (≥50% stenosis) on CCTA vs. No obstructive CAD. Primary outcome: Composite of mortality, myocardial infarction, or late coronary revascularization (≥90 days after CCTA) (HR 5.7, 95% CI 2.5 to 13.1, p=< 0.001).

Q: What question did this study set out to answer?

To determine the prevalence, severity, and prognostic impact of coronary artery disease in symptomatic patients with a coronary artery calcium score of zero undergoing coronary computed tomography angiography.

Todd C. Villines; Edward Hulten; Leslee J. Shaw; Manju Goyal; Allison Dunning; Stephan Achenbach; Mouaz H. Al‐Mallah; Daniel S. Berman; Matthew J. Budoff; Filippo Cademartiri; Tracy Q. Callister; Hyuk‐Jae Chang; Victor Cheng; Kavitha M. Chinnaiyan; Benjamin J.W. Chow; Augustin DeLago; Martin Hadamitzky; Jörg Hausleiter; Philipp A. Kaufmann; Fay Y. Lin; Erica Maffei; Gilbert Raff; James K. Min

doi:10.1016/j.jacc.2011.10.851

Key result

Obstructive CAD on CCTA is linked to a ~5.7-fold higher event risk despite zero CAC.

HR 5.7
95% CI 2.5 to 13.1
P<0.001
n=10,037

Why the study?

Does the presence of obstructive CAD on CCTA predict adverse events in symptomatic patients with a CAC score of 0?

Key Points

To determine the prevalence, severity, and prognostic impact of coronary artery disease in symptomatic patients with a coronary artery calcium score of zero undergoing coronary computed tomography angiography.
Evaluated 10,037 symptomatic patients without known coronary artery disease who underwent simultaneous coronary computed tomography angiography (CCTA) and coronary artery calcium (CAC) scoring.
Classified stenosis severity into <50%, ≥50%, and ≥70% categories.
Tracked all-cause mortality and a composite endpoint of death, myocardial infarction, or late coronary revascularization (≥90 days after CCTA) over a median follow-up of 2.1 years (n=8,907).
Among patients with a CAC score of 0, 84% had no coronary disease, 13% had nonobstructive stenosis, and 3.5% had obstructive CAD (≥50% stenosis, including 1.4% with ≥70% stenosis).
For the composite endpoint, patients with CAC = 0 and ≥50% stenosis had a significantly higher event rate than those with CAC = 0 and no obstructive CAD (3.9% vs. 0.8%; HR: 5.7; 95% CI: 2.5 to 13.1; p < 0.001), while all-cause mortality did not differ.
Adding the CAC score to CCTA findings provided no incremental prognostic value for predicting composite cardiovascular events (AUC 0.826 vs. 0.825; p = 0.84).

Study Design

Type

Cohort (n=10,037)

Structured PICO

Does the presence of obstructive CAD on CCTA predict adverse events in symptomatic patients with a CAC score of 0?

P

Population

10,037 symptomatic patients without known CAD undergoing concomitant CCTA and CAC scoring, followed for a median of 2.1 years.

E

Exposure

Presence of obstructive coronary artery disease (≥50% stenosis) on CCTA

C

Comparator

No obstructive coronary artery disease on CCTA

O

Outcome

All-cause mortality and the composite endpoint of mortality, myocardial infarction, or late coronary revascularization (≥90 days after CCTA) at median 2.1 years follow-upcomposite

Main Result

Hazard Ratio: 5.7 (95% CI 2.5–13.1)

Absolute Event Rate: 3.9% vs 0.8%

p-value: p=< 0.001

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

In symptomatic patients with a CAC score of 0, obstructive CAD is present in 3.5% of cases and is associated with a significantly increased risk of cardiovascular events, highlighting that a zero CAC score does not entirely rule out high-risk disease.

Abstract

OBJECTIVES The purpose of this study was to describe the prevalence and severity of coronary artery disease (CAD) in relation to prognosis in symptomatic patients without coronary artery calcification (CAC) undergoing coronary computed tomography angiography (CCTA). BACKGROUND The frequency and clinical relevance of CAD in patients without CAC are unclear. METHODS We identified 10,037 symptomatic patients without CAD who underwent concomitant CCTA and CAC scoring. CAD was assessed as <50%, ≥50%, and ≥70% stenosis. All-cause mortality and the composite endpoint of mortality, myocardial infarction, or late coronary revascularization (≥90 days after CCTA) were assessed. RESULTS Mean age was 57 years, 56% were men, and 51% had a CAC score of 0. Among patients with a CAC score of 0, 84% had no CAD, 13% had nonobstructive stenosis, and 3.5% had ≥50% stenosis (1.4% had ≥70% stenosis) on CCTA. A CAC score >0 had a sensitivity, specificity, and negative and positive predictive values for stenosis ≥50% of 89%, 59%, 96%, and 29%, respectively. During a median of 2.1 years, there was no difference in mortality among patients with a CAC score of 0 irrespective of obstructive CAD. Among 8,907 patients with follow-up for the composite endpoint, 3.9% with a CAC score of 0 and ≥50% stenosis experienced an event (hazard ratio: 5.7; 95% confidence interval: 2.5 to 13.1; p < 0.001) compared with 0.8% of patients with a CAC score of 0 and no obstructive CAD. Receiver-operator characteristic curve analysis demonstrated that the CAC score did not add incremental prognostic information compared with CAD extent on CCTA for the composite endpoint (CCTA area under the curve = 0.825; CAC + CCTA area under the curve = 0.826; p = 0.84). CONCLUSIONS In symptomatic patients with a CAC score of 0, obstructive CAD is possible and is associated with increased cardiovascular events. CAC scoring did not add incremental prognostic information to CCTA.

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Cite This Study

Villines et al. (2011) conducted a cohort in Symptomatic patients undergoing CCTA (n=10,037). Obstructive CAD (≥50% stenosis) on CCTA vs. No obstructive CAD was evaluated on Composite of mortality, myocardial infarction, or late coronary revascularization (≥90 days after CCTA) (HR 5.7, 95% CI 2.5 to 13.1, p=< 0.001). In symptomatic patients with a CAC score of 0, obstructive CAD on CCTA increased the risk of mortality, MI, or late revascularization compared to no obstructive CAD (HR 5.7; 95% CI 2.5-13.1).

synapsesocial.com/papers/6a8fac9aea87cdeb5c7a8b35 https://doi.org/10.1016/j.jacc.2011.10.851

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Prevalence and Severity of Coronary Artery Disease and Adverse Events Among Symptomatic Patients With Coronary Artery Calcification Scores of Zero Undergoing Coronary Computed Tomography Angiography

Key Points

Study Design

Structured PICO

Main Result

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Prevalence and Severity of Coronary Artery Disease and Adverse Events Among Symptomatic Patients With Coronary Artery Calcification Scores of Zero Undergoing Coronary Computed Tomography Angiography

Key Points

Study Design

Structured PICO

Main Result

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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