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Published on: August 28, 2018
Risk Stratification With the Use of Coronary Computed Tomographic Angiography in Patients With Nonobstructive
Jana Taron1, Borek Foldyna2, Thomas Mayrhofer3
1Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiology, University Hospital Freiburg, Freiburg, Germany.
Insights
High-risk plaque features in nonobstructive coronary artery disease (CAD) significantly predict cardiovascular events. Identifying these features improves risk prediction for patients with stable chest pain and nonobstructive CAD.
Area of Science:
- Cardiovascular Imaging and Diagnostics
- Interventional Cardiology
- Preventive Cardiology
Background:
- Most cardiovascular events in stable chest pain patients occur in those with nonobstructive coronary artery disease (CAD).
- Tailored risk prediction is needed for this patient group, considering both cardiovascular risk factors and CAD characteristics.
Purpose of the Study:
- To develop a risk prediction model specifically for patients diagnosed with nonobstructive CAD.
- To identify key predictors of cardiovascular events within the nonobstructive CAD population.
Main Methods:
- Utilized data from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial.
- Assessed CAD prevalence, degree of stenosis, high-risk plaque (HRP) features, segment involvement score (SIS), and coronary artery calcium (CAC) via computed tomographic angiography.
- Employed Cox regression analysis to determine independent predictors of composite cardiovascular events (unstable angina, myocardial infarction, death).
Main Results:
- In 2,614 patients with nonobstructive CAD, atherosclerotic cardiovascular disease (ASCVD) risk, degree of stenosis (30%–69%), and presence of ≥2 HRP features independently predicted composite events.
- The addition of ≥2 HRP features significantly improved risk prediction models that included ASCVD risk and either CAC, SIS, or degree of stenosis.
- Patients with ASCVD risk ≥7.5%, any HRP, and mild/moderate stenosis exhibited significantly higher event rates compared to those without these criteria.
Conclusions:
- Advanced coronary plaque features, beyond total plaque burden, incrementally enhance the discrimination of clinical events in stable chest pain patients with nonobstructive CAD.
- These findings represent a potential advancement in improving prevention strategies for this cohort, which carries the highest absolute risk for cardiovascular events.
Objectives:
The purpose of this study was to develop a risk prediction model for patients with nonobstructive CAD.
Background:
Among stable chest pain patients, most cardiovascular (CV) events occur in those with nonobstructive coronary artery disease (CAD). Thus, developing tailored risk prediction approaches in this group of patients, including CV risk factors and CAD characteristics, is needed.
Methods:
In PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) computed tomographic angiography patients, a core laboratory assessed prevalence of CAD (nonobstructive 1% to 49% left main or 1% to 69% stenosis any coronary artery), degree of stenosis (minimal: 1% to 29%; mild: 30% to 49%; or moderate: 50% to 69%), high-risk plaque (HRP) features (positive remodeling, low-attenuation plaque, and napkin-ring sign), segment involvement score (SIS), and coronary artery calcium (CAC). The primary end point was an adjudicated composite of unstable angina pectoris, nonfatal myocardial infarction, and death. Cox regression analysis determined independent predictors in nonobstructive CAD.
Results:
Of 2,890 patients (age 61.7 years, 46% women) with any CAD, 90.4% (n = 2,614) had nonobstructive CAD (mean age 61.6 yrs, 46% women, atherosclerotic cardiovascular disease [ASCVD] risk 16.2%). Composite events were independently predicted by ASCVD risk (hazard ratio [HR]: 1.03; p = 0.001), degree of stenosis (30% to 69%; HR: 1.91; p = 0.011), and presence of ≥2 HRP features (HR: 2.40; p = 0.008). Addition of ≥2 HRP features to: 1) ASCVD and CAC; 2) ASCVD and SIS; or 3) ASCVD and degree of stenosis resulted in a statistically significant improvement in model fit (p = 0.0036; p = 0.0176; and p = 0.0318; respectively). Patients with ASCVD ≥7.5%, any HRP, and mild/moderate stenosis had significantly higher event rates than those who did not meet those criteria (3.0% vs. 6.2%; p = 0.007).
Conclusions:
Advanced coronary plaque features have incremental value over total plaque burden for the discrimination of clinical events in low-risk stable chest pain patients with nonobstructive CAD. This may be a first step to improve prevention in this cohort with the highest absolute risk for CV events.
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