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Published on: August 28, 2018
The Coronary Artery Disease-Reporting and Data System (CAD-RADS): Prognostic and Clinical Implications Associated
Joe X Xie1, Ricardo C Cury2, Jonathon Leipsic3
1Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
Insights
The Coronary Artery Disease-Reporting and Data System (CAD-RADS) effectively identifies patients at risk for adverse events after coronary computed tomography angiography (CTA). However, invasive coronary angiography (ICA) is frequently used even in patients without severe disease.
Area of Science:
- Cardiovascular Imaging
- Radiology
- Clinical Decision Support
Background:
- Clinical decision support is crucial for guideline-directed care.
- Coronary Artery Disease-Reporting and Data System (CAD-RADS) standardizes coronary computed tomography angiography (CTA) reporting.
- CAD-RADS includes recommendations for post-CTA patient management.
Purpose of the Study:
- To assess clinical outcomes associated with CAD-RADS scores.
- To evaluate the utility of CAD-RADS in guiding post-CTA care.
- To determine the predictive value of CAD-RADS for adverse events.
Main Methods:
- Analysis of the multinational CONFIRM registry (5,039 patients).
- Stratification of patients by CAD-RADS scores (0-5) based on stenosis severity.
- Utilized Kaplan-Meier, Cox models, and ROC curves to assess mortality, myocardial infarction (MI), and compare CAD-RADS with other classifications.
- Assessed invasive coronary angiography (ICA) referral rates.
Main Results:
- Higher CAD-RADS scores correlated with increased risk of death or MI (5-year event-free survival 95.2% for CAD-RADS 0 to 69.3% for CAD-RADS 5).
- CAD-RADS demonstrated non-inferior predictive performance for death or MI compared to the Duke CAD Index and traditional classification (ROC 0.7052).
- High rates of ICA were observed for CAD-RADS 3 (66%) and CAD-RADS ≥4A (84%), with many patients lacking severe CAD or symptoms.
Conclusions:
- CAD-RADS effectively identifies patients at risk for adverse cardiovascular events.
- Frequent ICA use in patients with lower CAD-RADS scores suggests potential for overtreatment.
- Integrating CAD-RADS into CTA reports can enhance evidence-based post-procedural care.
Objectives:
This study sought to assess clinical outcomes associated with the novel Coronary Artery Disease-Reporting and Data System (CAD-RADS) scores used to standardize coronary computed tomography angiography (CTA) reporting and their potential utility in guiding post-coronary CTA care.
Background:
Clinical decision support is a major focus of health care policies aimed at improving guideline-directed care. Recently, CAD-RADS was developed to standardize coronary CTA reporting and includes clinical recommendations to facilitate patient management after coronary CTA.
Methods:
In the multinational CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry, 5,039 patients without known coronary artery disease (CAD) underwent coronary CTA and were stratified by CAD-RADS scores, which rank CAD stenosis severity as 0 (0%), 1 (1% to 24%), 2 (25% to 49%), 3 (50% to 69%), 4A (70% to 99% in 1 to 2 vessels), 4B (70% to 99% in 3 vessels or ≥50% left main), or 5 (100%). Kaplan-Meier and multivariable Cox models were used to estimate all-cause mortality or myocardial infarction (MI). Receiver-operating characteristic (ROC) curves were used to compare CAD-RADS to the Duke CAD Index and traditional CAD classification. Referrals to invasive coronary angiography (ICA) after coronary CTA were also assessed.
Results:
Cumulative 5-year event-free survival ranged from 95.2% to 69.3% for CAD-RADS 0 to 5 (p < 0.0001). Higher scores were associated with elevations in event risk (hazard ratio: 2.46 to 6.09; p < 0.0001). The ROC curve for prediction of death or MI was 0.7052 for CAD-RADS, which was noninferior to the Duke Index (0.7073; p = 0.893) and traditional CAD classification (0.7095; p = 0.783). ICA rates were 13% for CAD-RADS 0 to 2, 66% for CAD-RADS 3, and 84% for CAD-RADS ≥4A. For CAD-RADS 3, 58% of all catheterizations occurred within the first 30 days of follow-up. In a patient subset with available medication data, 57% of CAD-RADS 3 patients who received 30-day ICA were either asymptomatic or not receiving antianginal therapy at baseline, whereas only 32% had angina and were receiving medical therapy.
Conclusions:
CAD-RADS effectively identified patients at risk for adverse events. Frequent ICA use was observed among patients without severe CAD, many of whom were asymptomatic or not taking antianginal drugs. Incorporating CAD-RADS into coronary CTA reports may provide a novel opportunity to promote evidence-based care post-coronary CTA.
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