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Superior Risk Stratification With Coronary Computed Tomography Angiography Using a Comprehensive Atherosclerotic Risk
Alexander R van Rosendael1, Leslee J Shaw2, Joe X Xie2
1Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York.
Insights
A new comprehensive coronary computed tomography angiography (CTA) score improves risk prediction for cardiac events compared to the standard CAD-RADS assessment. This advanced CTA score better identifies patient risk by including plaque characteristics beyond just stenosis severity.
Area of Science:
- Cardiology
- Radiology
- Medical Imaging
Background:
- Current coronary computed tomography angiography (CTA) risk assessment primarily relies on maximal stenosis severity.
- Integrating plaque extent, location, and composition into a comprehensive model may enhance cardiovascular risk stratification.
Purpose of the Study:
- To evaluate the prognostic capability of a novel comprehensive coronary CTA score.
- To compare its performance against the stenosis severity component of the Coronary Artery Disease-Reporting and Data System (CAD-RADS).
Main Methods:
- A cohort of 2,134 patients with suspected coronary artery disease (CAD) was analyzed.
- The comprehensive CTA score (0-42) and CAD-RADS categories were compared for their predictive value.
- Internal and external validation using a 5-year follow-up dataset (n=1,971) was performed.
Main Results:
- The comprehensive CTA score demonstrated strong, independent predictive value for myocardial infarction or death.
- A model incorporating the comprehensive CTA score showed superior event discrimination (0.768) versus CAD-RADS (0.742).
- The comprehensive CTA score achieved significant net reclassification improvement (12.4%) and maintained accuracy in external validation.
Conclusions:
- The comprehensive CTA score offers improved risk discrimination and reclassification of cardiac events compared to stenosis-based CAD-RADS.
- Incorporating plaque characteristics enhances the prognostic accuracy of anatomic risk scores.
- The validated comprehensive CTA score provides a more robust tool for cardiovascular risk assessment.
Objectives:
This study was designed to assess the prognostic value of a new comprehensive coronary computed tomography angiography (CTA) score compared with the stenosis severity component of the Coronary Artery Disease-Reporting and Data System (CAD-RADS).
Background:
Current risk assessment with coronary CTA is mainly focused on maximal stenosis severity. Integration of plaque extent, location, and composition in a comprehensive model may improve risk stratification.
Methods:
A total of 2,134 patients with suspected but without known CAD were included. The predictive value of the comprehensive CTA score (ranging from 0 to 42 and divided into 3 groups: 0 to 5, 6 to 20, and >20) was compared with the CAD-RADS combined into 3 groups (0% to 30%, 30% to 70% and ≥70% stenosis). Its predictive performance was internally and externally validated (using the 5-year follow-up dataset of the CONFIRM [Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry], n = 1,971).
Results:
The mean age of patients was 55 ± 13 years, mean follow-up 3.6 ± 2.8 years, and 130 events (myocardial infarction or death) occurred. The new, comprehensive CTA score showed strong and independent predictive value using the Cox proportional hazard analysis. A model including clinical variables plus comprehensive CTA score showed better discrimination of events compared with a model consisting of clinical variables plus CAD-RADS (0.768 vs. 0.742, p = 0.001). Also, the comprehensive CTA score correctly reclassified a significant proportion of patients compared with the CAD-RADS (net reclassification improvement 12.4%, p < 0.001). Good predictive accuracy was reproduced in the external validation cohort.
Conclusions:
The new comprehensive CTA score provides better discrimination and reclassification of events compared with the CAD-RADS score based on stenosis severity only. The score retained similar prognostic accuracy when externally validated. Anatomic risk scores can be improved with the addition of extent, location, and compositional measures of atherosclerotic plaque. (Comprehensive CTA risk score calculator is available at: http://18.224.14.19/calcApp/).
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