Alexander R van Rosendael1,2, A Maxim Bax1, Jeff M Smit2, Inge J van den Hoogen1,2, Xiaoyue Ma3, Subhi Al'Aref1, Stephan Achenbach4, Mouaz H Al-Mallah5, Daniele Andreini6, Daniel S Berman7, Matthew J Budoff8, Filippo Cademartiri9, Tracy Q Callister10, Hyuk-Jae Chang11, Kavitha Chinnaiyan12, Benjamin J W Chow13, Ricardo C Cury14, Augustin DeLago15, Gudrun Feuchtner16, Martin Hadamitzky17, Joerg Hausleiter18, Philipp A Kaufmann19, Yong-Jin Kim20, Jonathon A Leipsic21, Erica Maffei22, Hugo Marques23, Pedro de Araújo Gonçalves23, Gianluca Pontone6, Gilbert L Raff12, Ronen Rubinshtein24, Todd C Villines25, Heidi Gransar26, Yao Lu3, Jessica M Peña1, Fay Y Lin1, Leslee J Shaw1, James K Min1, Jeroen J Bax2. 1. Department of Radiology, New York-Presbyterian Hospital, Weill Cornell Medicine, 413 East 69th St, Belfer Research Building, New York, NY 10021, USA. 2. Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands. 3. Department of Healthcare Policy and Research, New York-Presbyterian Hospital, Weill Cornell Medical College, 402 East 67th St, New York, NY 10065, USA. 4. Department of Cardiology, Friedrich-Alexander-University Erlangen-Nuremberg, Krankenhausstraße 12, 91054 Erlangen, Germany. 5. Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, 6565 Fannin St, Houston, TX 77030, USA. 6. Department of Radiology, Centro Cardiologico Monzino, IRCCS Milan, Via Carlo Parea 4, Milan, Lombardy 20138, Italy. 7. Department of Imaging and Medicine, Cedars Sinai Medical Center, 8700 Beverly Blvd, Taper 1258, Los Angeles, CA 90048, USA. 8. Department of Medicine, Los Angeles Biomedical Research Institute, 10833 Le Conte Ave, Torrance, Los Angeles, CA 90095, USA. 9. Department of Radiology, Cardiovascular Imaging Center, SDN IRCCS, Via Emanuele Gianturco 113, Naples, 80143 NA, Italy. 10. Department of Cardiology, Tennessee Heart and Vascular Institute, 353 New Shackle Island Rd, Ste 300C, Hendersonville, TN 37075, USA. 11. Division of Cardiology, Severance Cardiovascular Hospital, Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 50-1 Yonsei-Ro, Seodaemun-gu, Seoul 120-752, South Korea. 12. Department of Cardiology, William Beaumont Hospital, 3601 West 13 Mile Rd, Royal Oak, MI 48073, USA. 13. Department of Medicine and Radiology, University of Ottawa, 501 Smyth Rd, Ottawa, ON K1H 8L6, Canada. 14. Department of Radiology, Miami Cardiac and Vascular Institute, 8900 N Kendall Dr, Miami, FL 33176, USA. 15. Department of Cardiology, Capitol Cardiology Associates, 7 Southwoods Blvd, Albany, NY 12211, USA. 16. Department of Radiology, Medical University of Innsbruck, Christoph-Probst-Platz 1, Innrain 52A, 6020 Innsbruck, Austria. 17. Department of Radiology and Nuclear Medicine, German Heart Center Munich, Lazarettstraße 36, 80636 Munich, Germany. 18. Department of Cardiology, Medizinische Klinik I der Ludwig-Maximilians-Universität München, Ziemssenstraße 1, 80336 Munich, Germany. 19. Department of Nuclear Medicine, University Hospital, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland. 20. Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Yeongeon-dong, Jongno-gu, Seoul, South Korea. 21. Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, BC V6T 1Z4, Canada. 22. Department of Radiology, Area Vasta 1/ASUR Marche, Via Ceccarini, Urbino, 61302 Fano PU, Italy. 23. UNICA, Unit of Cardiovascular Imaging, Hospital da Luz, Av. Lusíada 100, 1500-650 Lisboa, Portugal. 24. Department of Cardiology, Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Mikhal St 7, Haifa, 3436212, Israel. 25. Department of Medicine, University of Virginia Health System, 1215 Lee St, Charlottesville, VA 22903, USA. 26. Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA.
Abstract
AIMS: In patients without obstructive coronary artery disease (CAD), we examined the prognostic value of risk factors and atherosclerotic extent. METHODS AND RESULTS: Patients from the long-term CONFIRM registry without prior CAD and without obstructive (≥50%) stenosis were included. Within the groups of normal coronary computed tomography angiography (CCTA) (N = 1849) and non-obstructive CAD (N = 1698), the prognostic value of traditional clinical risk factors and atherosclerotic extent (segment involvement score, SIS) was assessed with Cox models. Major adverse cardiac events (MACE) were defined as all-cause mortality, non-fatal myocardial infarction, or late revascularization. In total, 3547 patients were included (age 57.9 ± 12.1 years, 57.8% male), experiencing 460 MACE during 5.4 years of follow-up. Age, body mass index, hypertension, and diabetes were the clinical variables associated with increased MACE risk, but the magnitude of risk was higher for CCTA defined atherosclerotic extent; adjusted hazard ratio (HR) for SIS >5 was 3.4 (95% confidence interval [CI] 2.3-4.9) while HR for diabetes and hypertension were 1.7 (95% CI 1.3-2.2) and 1.4 (95% CI 1.1-1.7), respectively. Exclusion of revascularization as endpoint did not modify the results. In normal CCTA, presence of ≥1 traditional risk factors did not worsen prognosis (log-rank P = 0.248), while it did in non-obstructive CAD (log-rank P = 0.025). Adjusted for SIS, hypertension and diabetes predicted MACE risk in non-obstructive CAD, while diabetes did not increase risk in absence of CAD (P-interaction = 0.004). CONCLUSION: Among patients without obstructive CAD, the extent of CAD provides more prognostic information for MACE than traditional cardiovascular risk factors. An interaction was observed between risk factors and CAD burden, suggesting synergistic effects of both. Published on behalf of the European Society of Cardiology. All rights reserved.
AIMS: In patients without obstructive coronary artery disease (CAD), we examined the prognostic value of risk factors and atherosclerotic extent. METHODS AND RESULTS:Patients from the long-term CONFIRM registry without prior CAD and without obstructive (≥50%) stenosis were included. Within the groups of normal coronary computed tomography angiography (CCTA) (N = 1849) and non-obstructive CAD (N = 1698), the prognostic value of traditional clinical risk factors and atherosclerotic extent (segment involvement score, SIS) was assessed with Cox models. Major adverse cardiac events (MACE) were defined as all-cause mortality, non-fatal myocardial infarction, or late revascularization. In total, 3547 patients were included (age 57.9 ± 12.1 years, 57.8% male), experiencing 460 MACE during 5.4 years of follow-up. Age, body mass index, hypertension, and diabetes were the clinical variables associated with increased MACE risk, but the magnitude of risk was higher for CCTA defined atherosclerotic extent; adjusted hazard ratio (HR) for SIS >5 was 3.4 (95% confidence interval [CI] 2.3-4.9) while HR for diabetes and hypertension were 1.7 (95% CI 1.3-2.2) and 1.4 (95% CI 1.1-1.7), respectively. Exclusion of revascularization as endpoint did not modify the results. In normal CCTA, presence of ≥1 traditional risk factors did not worsen prognosis (log-rank P = 0.248), while it did in non-obstructive CAD (log-rank P = 0.025). Adjusted for SIS, hypertension and diabetes predicted MACE risk in non-obstructive CAD, while diabetes did not increase risk in absence of CAD (P-interaction = 0.004). CONCLUSION: Among patients without obstructive CAD, the extent of CAD provides more prognostic information for MACE than traditional cardiovascular risk factors. An interaction was observed between risk factors and CAD burden, suggesting synergistic effects of both. Published on behalf of the European Society of Cardiology. All rights reserved.
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