Allison Dunning

Coronary Computed Tomographic Angiography as a Gatekeeper to Invasive Diagnostic and Surgical Procedures : Results From the Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) Registry

OBJECTIVESnThis study sought to examine patterns of follow-up invasive coronary angiography (ICA) and revascularization (REV) after coronary computed tomography angiography (CCTA).nnnBACKGROUNDnCCTA is a noninvasive test that permits direct visualization of the extent and severity of coronary artery disease (CAD). Post-CCTA patterns of follow-up ICA and REV are incompletely defined.nnnMETHODSnWe examined 15,207 intermediate likelihood patients from 8 sites in 6 countries; these patients were without known CAD, underwent CCTA, and were followed up for 2.3 ± 1.2 years for all-cause mortality. Coronary artery stenosis was judged as obstructive when ≥50% stenosis was present. A multivariable logistic regression was used to estimate ICA use. A Cox proportional hazards model was used to estimate all-cause mortality.nnnRESULTSnDuring follow-up, ICA rates for patients with no CAD to mild CAD according to CCTA were low (2.5% and 8.3%), with similarly low rates of REV (0.3% and 2.5%). Most ICA procedures (79%) occurred ≤3 months of CCTA. Obstructive CAD was associated with higher rates of ICA and REV for 1-vessel (44.3% and 28.0%), 2-vessel (53.3% and 43.6%), and 3-vessel (69.4% and 66.8%) CAD, respectively. For patients with <50% stenosis, early ICA rates were elevated; over the entirety of follow-up, predictors of ICA were mild left main, mild proximal CAD, respectively, or higher coronary calcium scores. In patients with <50% stenosis, the relative hazard for death was 2.2 (p = 0.011) for ICA versus no ICA. Conversely, for patients with CAD, the relative hazard for death was 0.61 for ICA versus no ICA (p = 0.047).nnnCONCLUSIONSnThese findings support the concept that CCTA may be used effectively as a gatekeeper to ICA.

Prognostic and Therapeutic Implications of Statin and Aspirin Therapy in Individuals With Nonobstructive Coronary Artery Disease Results From the CONFIRM (Coronary CT Angiography Evaluation For Clinical Outcomes: An International Multicenter Registry) Registry

Objective— We sought to examine the risk of mortality associated with nonobstructive coronary artery disease (CAD) and to determine the impact of baseline statin and aspirin use on mortality. Approach and Results— Coronary computed tomographic angiography permits direct visualization of nonobstructive CAD. To date, the prognostic implications of nonobstructive CAD and the potential benefit of directing therapy based on nonobstructive CAD have not been carefully examined. A total of 27 125 consecutive patients who underwent computed tomographic angiography (12 enrolling centers and 6 countries) were prospectively entered into the COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter (CONFIRM) registry. Patients, without history of previous CAD or obstructive CAD, for whom baseline statin and aspirin use was available were analyzed. Each coronary segment was classified as normal or nonobstructive CAD (1%–49% stenosis). Patients were followed up for a median of 27.2 months for all-cause mortality. The study comprised 10 418 patients (5712 normal and 4706 with nonobstructive CAD). In multivariable analyses, patients with nonobstructive CAD had a 6% (95% confidence interval, 1%–12%) higher risk of mortality for each additional segment with nonobstructive plaque (P=0.021). Baseline statin use was associated with a reduced risk of mortality (hazard ratio, 0.44; 95% confidence interval, 0.28–0.68; P=0.0003), a benefit that was present for individuals with nonobstructive CAD (hazard ratio, 0.32; 95% confidence interval, 0.19–0.55; P<0.001) but not for those without plaque (hazard ratio, 0.66; 95% confidence interval, 0.30–1.43; P=0.287). When stratified by National Cholesterol Education Program/Adult Treatment Program III, no mortality benefit was observed in individuals without plaque. Aspirin use was not associated with mortality benefit, irrespective of the status of plaque. Conclusions— The presence and extent of nonobstructive CAD predicted mortality. Baseline statin therapy was associated with a significant reduction in mortality for individuals with nonobstructive CAD but not for individuals without CAD. Clinical Trial Registration— URL: http://clinicaltrials.gov/. Unique identifier NCT01443637

Coronary CT Angiography of Patients With a Normal Body Mass Index Using 80 kVp Versus 100 kVp: A Prospective, Multicenter, Multivendor Randomized Trial

OBJECTIVEnWe determined the effect of reduced 80-kVp tube voltage on the radiation dose and image quality of coronary CT angiography (CTA) in patients with a normal body mass index (BMI).nnnSUBJECTS AND METHODSnA prospective, multicenter, multivendor trial was performed of 208 consecutive patients with a normal BMI (< 25 kg/m(2)) who had been referred for coronary CTA and did not have a history of coronary revascularization. Patients were randomized to 80-kVp imaging (n = 103) or 100-kVp imaging (n = 105). Three blinded readers graded interpretability and image quality. Study signal, noise, and contrast were also compared.nnnRESULTSnImaging with 80 kVp instead of 100 kVp was associated with 47% lower median radiation dose (median dose-length product, 62.0 mGy · cm [interquartile range, 54.0-123.3 mGy · cm] vs 117.0 mGy · cm [110.0-225.9 mGy · cm], respectively; 0.9 mSv [0.8-1.7 mSv] vs 1.6 mSv [1.4-3.2 mSv]; p < 0.001 for each) with no significant difference in interpretability (99% vs 99%; p = 0.99) or image quality (median score, 4.0 [interquartile range, 3.6-4.0] vs 4.0 [interquartile range, 3.8-4.0]; p = 0.20). Studies obtained using 80 kVp were associated with 27% increased signal (mean ± SD, 756 ± 157 vs 594 ± 105 HU; p < 0.001), 25% higher contrast (890 ± 156 vs 709 ± 108 HU; p < 0.001), and 50% greater noise (55 ± 15 vs 37 ± 12 HU; p < 0.001) with resultant 15% and 16% decreases in signal-to-noise (mean ± SD, 15 ± 5 vs 17 ± 5; p < 0.001) and contrast-to-noise (mean ± SD, 17 ± 6 vs 21 ± 5; p < 0.001) ratios, respectively.nnnCONCLUSIONnCoronary CTA using 80 kVp instead of 100 kVp was associated with a nearly 50% reduction in radiation dose with no significant difference in interpretability and noninferior image quality despite lower signal-to-noise and contrast-to-noise ratios. The use of 80-kVp tube voltage should be considered in dose-reduction strategies for coronary CTA of individuals with a normal BMI.

Sex-based Prognostic Implications of Nonobstructive Coronary Artery Disease: Results from the International Multicenter CONFIRM Study

PURPOSEnTo determine the clinical outcomes of women and men with nonobstructive coronary artery disease ( CAD coronary artery disease ) with coronary computed tomographic (CT) angiography data in patients who were similar in terms of CAD coronary artery disease risk factors, angina typicality, and CAD coronary artery disease extent and distribution.nnnMATERIALS AND METHODSnInstitutional review board approval was obtained for all participating sites, with either informed consent or waiver of informed consent. In a prospective international multicenter cohort study of 27 125 patients undergoing coronary CT angiography at 12 centers, 18 158 patients with no CAD coronary artery disease or nonobstructive (<50% stenosis) CAD coronary artery disease were examined. Men and women were propensity matched for age, CAD coronary artery disease risk factors, angina typicality, and CAD coronary artery disease extent and distribution, which resulted in a final cohort of 11 462 subjects. Nonobstructive CAD coronary artery disease presence and extent were related to incident major adverse cardiovascular events ( MACE major adverse cardiovascular events ), which were inclusive of death and myocardial infarction and were estimated by using multivariable Cox proportional hazards models.nnnRESULTSnAt a mean follow-up ± standard deviation of 2.3 years ± 1.1, MACE major adverse cardiovascular events occurred in 164 patients (0.6% annual event rate). After matching, women and men experienced identical annualized rates of myocardial infarction (0.2% vs 0.2%, P = .72), death (0.5% vs 0.5%, P = .98), and MACE major adverse cardiovascular events (0.6% vs 0.6%, P = .94). In multivariable analysis, nonobstructive CAD coronary artery disease was associated with similarly increased MACE major adverse cardiovascular events for both women (hazard ratio: 1.96 [95% confidence interval { CI confidence interval }: 1.17, 3.28], P = .01) and men (hazard ratio: 1.77 [95% CI confidence interval : 1.07, 2.93], P = .03).nnnCONCLUSIONnWhen matched for age, CAD coronary artery disease risk factors, angina typicality, and nonobstructive CAD coronary artery disease extent, women and men experience comparable rates of incident mortality and myocardial infarction.

Prognostic significance of calcified plaque among symptomatic patients with nonobstructive coronary artery disease

BackgroundCoronary artery calcium (CAC) is a well-established predictor of clinical outcomes for population screening. Limited evidence is available as to its predictive value in symptomatic patients without obstructive coronary artery disease (CAD). The aim of the current study was to assess the prognostic value of CAC scores among symptomatic patients with nonobstructive CAD.MethodsFrom the COronary Computed Tomographic Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter (CONFIRM) registry, 7,200 symptomatic patients with nonobstructive CAD (<50% coronary stenosis) on coronary-computed tomographic angiography were prospectively enrolled and followed for a median of 2.1xa0years. Patients were categorized as without (0% stenosis) or with (>0% but <50% coronary stenosis) a luminal stenosis. CAC scores were calculated using the Agatston method. Univariable and multivariable Cox proportional hazard models were employed to estimate all-cause mortality and/or myocardial infarction (MI). Four-year death and death or MI rates were 1.9% and 3.3%.ResultsOf the 4,380 patients with no luminal stenosis, 86% had CAC scores of <10 while those with a luminal stenosis had more prevalent and extensive CAC with 31.9% having a CAC score of ≥100. Among patients with no luminal stenosis, CAC was not predictive of all-cause mortality (Pxa0=xa0.44). However, among patients with a luminal stenosis, 4-year mortality rates ranged from 0.8% to 9.8% for CAC scores of 0 to ≥400 (Pxa0<xa0.0001). The mortality hazard was 6.0 (Pxa0=xa0.004) and 13.3 (Pxa0<xa0.0001) for patients with a CAC score of 100-399 and ≥400. In patients with a luminal stenosis, CAC remained independently predictive in all-cause mortality (Pxa0<xa0.0001) and death or MI (Pxa0<xa0.0001) in multivariable models containing CAD risk factors and presenting symptoms.ConclusionsCAC allows for the identification of those at an increased hazard for death or MI in symptomatic patients with nonobstructive disease. From the CONFIRM registry, the extent of CAC was an independent estimator of long-term prognosis among symptomatic patients with luminal stenosis and may further define risk and guide preventive strategies in patients with nonobstructive CAD.

DEGREE OF LEFT VENTRICULAR SYSTOLIC DYSFUNCTION BY CARDIAC COMPUTED TOMOGRAPHIC ANGIOGRAPHY IMPROVES RISK STRATIFICATION AND DISCRIMINATION OF PATIENTS AT RISK FOR INCIDENT MORTALITY: RESULTS FROM 7907 PATIENTS IN THE PROSPECTIVE MULTICENTER INTERNATIONAL CONFIRM STUDY

Prior studies have evaluated the prognostic utility of left ventricular systolic dysfunction (LVSD) by cardiac CT angiography (CCTA), but have been limited to measures of normal versus abnormal function. Whether the degree of LVSD improves risk stratification and discrimination for mortality

NONOBSTRUCTIVE LEFT MAIN CORONARY ARTERY DISEASE ON CORONARY CT ANGIOGRAPHY AND RISK FOR MYOCARDIAL INFARCTION

Patients with obstructive left main (LM) disease (≥50% stenosis) are at high risk for future adverse cardiovascular events. However, outcomes among those with nonobstructive LM (1-49% stenosis) are not well defined.nnIn the prospective COronary CT Angiography EvaluatioN For Clinical Outcomes: An

DIFFERENTIAL IMPACT OF TRADITIONAL RISK FACTORS FOR PREDICTING THE PROBABILITY OF OBSTRUCTIVE CORONARY ARTERY DISEASE IN MEN AND WOMEN WITH CHEST PAIN: RESULTS FROM THE MULTINATIONAL CONFIRM REGISTRY

Whether certain traditional risk factors (RFs) provide greater predictive strength for obstructive coronary artery disease (≥50p diameter stenosis, “OCAD”) in patients with chest pain is unknown.nnFrom 8106 consecutive patients (mean age 58 years, 3999 men) without CAD history

DOES NONCALCIFIED PLAQUE IMPROVE THE DIAGNOSTIC AND PROGNOSTIC UTILITY OF CORONARY CT ANGIOGRAPHY? A STUDY OF PROPENSITY-MATCHED INDIVIDUALS WITH SIMILAR CORONARY CALCIUM SCORES FROM THE PROSPECTIVE MULTICENTER INTERNATIONAL CONFIRM REGISTRY

Calcified plaque (CP) on non-contrast coronary calcium scoring (CCS) robustly predicts future major adverse cardiac events (MACE). Noncalcified plaques (NCP) are detectable by contrast-enhanced coronary CT angiography (CCTA), but whether NCP improves diagnostic and prognostic utility beyond CCS