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Cited by 125Cardiac Imaging and DiagnosticsCoronary Interventions and DiagnosticsCoronary Artery Anomalies

Does coronary CT angiography improve risk stratification over coronary calcium scoring in symptomatic patients with suspected coronary artery disease? Results from the prospective multicenter international CONFIRM registry

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Al-Mallah, M. H., Qureshi, W., Lin, F. Y., Achenbach, S., Berman, D. S., Budoff, M. J., Callister, T. Q., Chang, H.-J. +20 more·2014·European Heart Journal - Cardiovascular Imaging
DOI 10.1093/ehjci/jet148
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Abstract

AIMS: The prognostic value of coronary artery calcium (CAC) scoring is well established and has been suggested for use to exclude significant coronary artery disease (CAD) for symptomatic individuals with CAD. Contrast-enhanced coronary computed tomographic angiography (CCTA) is an alternative modality that enables direct visualization of coronary stenosis severity, extent, and distribution. Whether CCTA findings of CAD add an incremental prognostic value over CAC in symptomatic individuals has not been extensively studied. METHODS AND RESULTS: We prospectively identified symptomatic patients with suspected but without known CAD who underwent both CAC and CCTA. Symptoms were defined by the presence of chest pain or dyspnoea, and pre-test likelihood of obstructive CAD was assessed by the method of Diamond and Forrester (D-F). CAC was measured by the method of Agatston. CCTAs were graded for obstructive CAD (>70% stenosis); and CAD plaque burden, distribution, and location. Plaque burden was determined by a segment stenosis score (SSS), which reflects the number of coronary segments with plaque, weighted for stenosis severity. Plaque distribution was established by a segment-involvement score (SIS), which reflects the number of segments with plaque irrespective of stenosis severity. Finally, a modified Duke prognostic index-accounting for stenosis severity, plaque distribution, and plaque location-was calculated. Nested Cox proportional hazard models for a composite endpoint of all-cause mortality and non-fatal myocardial infarction (D/MI) were employed to assess the incremental prognostic value of CCTA over CAC. A total of 8627 symptomatic patients (50% men, age 56 ± 12 years) followed for 25 months (interquartile range 17-40 months) comprised the study cohort. By CAC, 4860 (56%) and 713 (8.3%) patients had no evident calcium or a score of >400, respectively. By CCTA, 4294 (49.8%) and 749 (8.7%) had normal coronary arteries or obstructive CAD, respectively. At follow-up, 150 patients experienced D/MI. CAC improved discrimination beyond D-F and clinical variables (area under the receiver-operator characteristic curve 0.781 vs. 0.788, P = 0.004). When added sequentially to D-F, clinical variables, and CAC, all CCTA measures of CAD improved discrimination of patients at risk for D/MI: obstructive CAD (0.82, P < 0.001), SSS (0.81, P < 0.001), SIS (0.81, P = 0.003), and Duke CAD prognostic index (0.82, P < 0.0001). CONCLUSION: In symptomatic patients with suspected CAD, CCTA adds incremental discriminatory power over CAC for discrimination of individuals at risk of death or MI.

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  • The SSS and SIS have demonstrated clinical validity in detecting major adverse cardiac events in multiple populations.

    “The SSS and SIS have demonstrated clinical validity in detecting major adverse cardiac events in multiple populations.15–19”

    From Lifelong endurance exercise and its relation with coronary atherosclerosis (2023) · cites this paper as [15]

    The Multivariable Cox models section reports that adding SSS or SIS improved prediction of death or myocardial infarction, and Table 3 shows improved C-statistics for both scores. The evidence comes from one multicenter cohort of symptomatic patients with suspected coronary artery disease, not multiple distinct populations; the measured endpoint was all-cause mortality or non-fatal MI. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

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Authors
Al-Mallah, M. H., Qureshi, W., Lin, F. Y., Achenbach, S., Berman, D. S., Budoff, M. J., Callister, T. Q., Chang, H.-J., Cademartiri, F., Chinnaiyan, K., Chow, B. J. W., Cheng, V. Y., DeLago, A., Gomez, M., Hadamitzky, M., Hausleiter, J., Kaufmann, P. A., Leipsic, J., Maffei, E., Raff, G., Shaw, L. J., Villines, T. C., Cury, R. C., Feuchtner, G., Plank, F., Kim, Y.-J., Dunning, A. M., & Min, J. K.
Affiliations
  • Wayne State University (US)
  • NewYork–Presbyterian Hospital (US)
  • Friedrich-Alexander-Universität Erlangen-Nürnberg (DE)
  • Cedars-Sinai Medical Center (US)
  • Harbor–UCLA Medical Center (US)
  • Severance Hospital (KR)
  • Corewell Health William Beaumont University Hospital (US)
  • University of Ottawa (CA)
  • Oklahoma Heart Institute (US)
  • Capital Cardiology Associates (US)
  • Deutsches Herzzentrum München (DE)
  • University Hospital Zurich (CH)
  • University of British Columbia (CA)
  • Emory University (US)
  • Baptist Hospital of Miami (US)
  • Innsbruck Medical University (AT)
  • Seoul National University Hospital (KR)
Corresponding author
Al-Mallah, M. H.
ORCID
Venue
European Heart Journal - Cardiovascular Imaging
Publisher
Oxford University Press (OUP)
Published
2013-08-21
Volume
15
Issue
3
Pages
267-274
ISSN
  • 2047-2404 (ISSN-L)
  • 2047-2412
DOI
10.1093/ehjci/jet148
OpenAlex
W2082004512
Cited by
125
References
1
Citations by year
2026: 2 · 2025: 3 · 2024: 6 · 2023: 13 · 2022: 4 · 2021: 12 · 2020: 11 · 2019: 10 · 2018: 6 · 2017: 11 · 2016: 16 · 2015: 21 · 2014: 7 · 2013: 3
FWCI
12.10
Type
journal article
Language
en
Open access
Locations
  • European Heart Journal - Cardiovascular Imaging (publishedVersion)
  • PubMed (publishedVersion)
  • Zurich Open Repository and Archive (University of Zurich) (acceptedVersion)
  • YUHSpace (Yonsei University Medical Library) (submittedVersion, cc-by-nc-nd)
  • mediaTUM (Technical University of Munich) (submittedVersion)
  • OPUS FAU (Kooperativer Bibliotheksverbund Berlin-Brandenburg (KOBV), on behalf of the Universitätsbibliothek Erlangen-Nürnberg) (submittedVersion)
  • Zurich Open Repository and Archive (University of Zurich) (submittedVersion)
Topics
  • Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
  • Health Sciences › Medicine › Surgery › Coronary Interventions and Diagnostics
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Coronary Artery Anomalies
Keywords
coronary CT angiography, coronary artery calcium scoring, risk stratification, coronary artery disease, symptomatic patients, incremental prognostic value, obstructive coronary artery disease, plaque burden, segment involvement score, all-cause mortality, nonfatal myocardial infarction, CONFIRM registry
MeSH terms
Adult, Aged, Calcium, Contrast Media, Female, Follow-Up Studies, Humans, Male, Middle Aged, Myocardial Infarction, Predictive Value of Tests, Prospective Studies, Registries, Time Factors, Tomography, X-Ray Computed, Cohort Studies, Survival Rate, Proportional Hazards Models, Coronary Angiography, Risk Assessment, Coronary Stenosis, Kaplan-Meier Estimate, Plaque, Atherosclerotic

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