Michael K Cheezum1, Prem Srinivas Subramaniyam2, Marcio S Bittencourt3, Edward A Hulten4, Brian B Ghoshhajra5, Nishant R Shah1, Daniel E Forman1, Jon Hainer1, Marcia Leavitt2, Ram Padmanabhan2, Hicham Skali1, Sharmila Dorbala1, Udo Hoffmann5, Suhny Abbara6, Marcelo F Di Carli1, Henry Gewirtz2, Ron Blankstein7. 1. Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA. 2. Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. 3. Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA Center for Clinical and Epidemiological Research, Division of Internal Medicine, University of São Paulo, São Paulo, Brazil. 4. Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA Cardiology Service, Division of Medicine, Walter Reed National Military Medical Center and Uniformed Services University of Health Sciences, Bethesda, MD, USA. 5. Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. 6. Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA. 7. Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA rblankstein@partners.org.
Abstract
AIMS: We sought to compare the complementary prognostic value of exercise treadmill testing (ETT) and coronary computed tomographic angiography (CTA) among patients referred for both exams. METHODS AND RESULTS: We studied 582 patients without known coronary artery disease (CAD) who were clinically referred for ETT and CTA within 6 months. Patients were followed for cardiovascular (CV) death, non-fatal myocardial infarction (MI), or late revascularization (>90 days), stratified by Duke Treadmill Score (DTS) and CAD severity (≥50% stenosis). Mean age was 54 ± 13 years (63% male). In median follow-up of 40 months, there were 3 CV deaths, 7 non-fatal MIs, and 26 late revascularizations. ETT was inconclusive in 23%, positive in 31%, and negative in 46%. CTA demonstrated no CAD in 37%, non-obstructive CAD in 28%, and obstructive CAD in 35%. Among low-risk ETT patients (n = 326), there were 3 MI, 10 late revascularizations, and the frequent presence of non-obstructive (32%, n = 105) and obstructive CAD (27%, n = 88). When present, ETT features (i.e., angina, DTS, ischaemic electrocardiogram changes, and exercise capacity) individually failed to predict CV death/MI after adjustment for Morise score. Conversely, both obstructive CAD [HR 4.9 (1.0-23.3), P = 0.048] and CAD extent by segment involvement score >4 [HR 3.9 (1.0-15.2), P = 0.049] predicted increased risk for CV death or MI. CONCLUSION: Patients with a low-risk ETT have an excellent prognosis at 40 months, despite the frequent presence of non-obstructive (32%) and obstructive (27%) CAD. In patients with an intermediate- to high-risk ETT (DTS <5), CTA can provide incremental risk stratification for future CV events. Published by Oxford University Press on behalf of the European Society of Cardiology 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.
AIMS: We sought to compare the complementary prognostic value of exercise treadmill testing (ETT) and coronary computed tomographic angiography (CTA) among patients referred for both exams. METHODS AND RESULTS: We studied 582 patients without known coronary artery disease (CAD) who were clinically referred for ETT and CTA within 6 months. Patients were followed for cardiovascular (CV) death, non-fatal myocardial infarction (MI), or late revascularization (>90 days), stratified by Duke Treadmill Score (DTS) and CAD severity (≥50% stenosis). Mean age was 54 ± 13 years (63% male). In median follow-up of 40 months, there were 3 CV deaths, 7 non-fatal MIs, and 26 late revascularizations. ETT was inconclusive in 23%, positive in 31%, and negative in 46%. CTA demonstrated no CAD in 37%, non-obstructive CAD in 28%, and obstructive CAD in 35%. Among low-risk ETTpatients (n = 326), there were 3 MI, 10 late revascularizations, and the frequent presence of non-obstructive (32%, n = 105) and obstructive CAD (27%, n = 88). When present, ETT features (i.e., angina, DTS, ischaemic electrocardiogram changes, and exercise capacity) individually failed to predict CV death/MI after adjustment for Morise score. Conversely, both obstructive CAD [HR 4.9 (1.0-23.3), P = 0.048] and CAD extent by segment involvement score >4 [HR 3.9 (1.0-15.2), P = 0.049] predicted increased risk for CV death or MI. CONCLUSION:Patients with a low-risk ETT have an excellent prognosis at 40 months, despite the frequent presence of non-obstructive (32%) and obstructive (27%) CAD. In patients with an intermediate- to high-risk ETT (DTS <5), CTA can provide incremental risk stratification for future CV events. Published by Oxford University Press on behalf of the European Society of Cardiology 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.
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