Stable angina pectoris: head-to-head comparison of prognostic value of cardiac CT and exercise testing
Admir Dedic1, Tessa S S Genders, Bart S Ferket
1Department of Cardiology, Erasmus University Medical Centre, 's-Gravendijkwal 230, PO Box 2040, 3000 CA Rotterdam, The Netherlands. a.dedic@erasmusmc.nl
Insights
Cardiac CT angiography is a strong predictor of future cardiac events, outperforming coronary calcium scoring and exercise ECG in patients with suspected coronary artery disease.
Area of Science:
- Cardiology
- Radiology
- Medical Imaging
Background:
- Coronary artery disease (CAD) is a leading cause of mortality worldwide.
- Accurate risk stratification in patients with suspected CAD is crucial for timely intervention.
- Non-invasive imaging modalities are increasingly used to evaluate coronary artery disease.
Purpose of the Study:
- To compare the prognostic value of cardiac computed tomographic (CT) angiography, coronary calcium scoring, and exercise electrocardiography (ECG) in patients presenting with chest pain and suspected CAD.
- To determine which imaging modality provides the most accurate prediction of major adverse cardiac events (MACE).
Main Methods:
- A prospective study of 471 patients without known CAD who underwent exercise ECG and dual-source CT.
- CT assessed coronary calcification and obstructive coronary stenosis (≥50%).
- Exercise ECG results were categorized as normal, ischemic, or nondiagnostic. Major adverse cardiac events (MACE) were tracked for a mean of 2.6 years.
Main Results:
- Cardiac CT angiography findings (HR, 5.0) and nondiagnostic exercise ECG results (HR, 2.9) were independent predictors of MACE in multivariable analysis.
- CT angiography demonstrated incremental prognostic value beyond clinical factors and stress testing (P < .001).
- Coronary calcium scoring did not show further incremental value over CT angiography findings.
Conclusions:
- Cardiac CT angiography is a powerful predictor of future adverse cardiac events in patients with suspected CAD.
- CT angiography offers superior prognostic information compared to coronary calcium scoring and exercise ECG.
- These findings support the use of CT angiography in the risk stratification of patients with chest pain.
Purpose:
To determine and compare the prognostic value of cardiac computed tomographic (CT) angiography, coronary calcium scoring, and exercise electrocardiography (ECG) in patients with chest pain who are suspected of having coronary artery disease (CAD).
Materials And Methods:
This study complied with the Declaration of Helsinki, and the local ethics committee approved the study. Patients (n = 471) without known CAD underwent exercise ECG and dual-source CT at a rapid assessment outpatient chest pain clinic. Coronary calcification and the presence of 50% or greater coronary stenosis (in one or more vessels) were assessed with CT. Exercise ECG results were classified as normal, ischemic, or nondiagnostic. The primary outcome was a major adverse cardiac event (MACE), defined as cardiac death, nonfatal myocardial infarction, or unstable angina requiring hospitalization and revascularization beyond 6 months. Univariable and multivariable Cox regression analysis was used to determine the prognostic values, while clinical impact was assessed with the net reclassification improvement metric.
Results:
Follow-up was completed for 424 (90%) patients; the mean duration of follow-up was 2.6 years. A total of 44 MACEs occurred in 30 patients. Four of the MACEs were cardiac deaths and six were nonfatal myocardial infarctions. The presence of coronary calcification (hazard ratio [HR], 8.22 [95% confidence interval {CI}: 1.96, 34.51]), obstructive CAD (HR, 6.22 [95% CI: 2.77, 13.99]), and nondiagnostic stress test results (HR, 3.00 [95% CI: 1.26, 7.14]) were univariable predictors of MACEs. In the multivariable model, CT angiography findings (HR, 5.0 [95% CI: 1.7, 14.5]) and nondiagnostic exercise ECG results (HR, 2.9 [95% CI: 1.2, 7.0]) remained independent predictors of MACEs. CT angiography findings showed incremental value beyond clinical predictors and stress testing (global χ(2), 37.7 vs 13.7; P < .001), whereas coronary calcium scores did not have further incremental value (global χ(2), 38.2 vs 37.7; P = .40).
Conclusion:
CT angiography findings are a strong predictor of future adverse events, showing incremental value over clinical predictors, stress testing, and coronary calcium scores.
Supplemental Material:
http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11110744/-/DC1.
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