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Adverse Cardiovascular Events Among Younger and Older Patients Referred for Coronary CTA: The Mass General Brigham
Daniel M Huck1, Adam N Berman2, Arthur Shiyovich1
1Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Insights
Coronary computed tomography angiography (CTA) is valuable for older adults, identifying obstructive coronary artery disease (CAD) and extensive plaque associated with major adverse cardiovascular events (MACE). Further refinement in risk stratification for nonobstructive plaque is needed, especially in this demographic.
Area of Science:
- Cardiovascular Imaging and Diagnostics
- Geriatric Cardiology
- Radiology
Background:
- Coronary computed tomography angiography (CTA) is recommended for younger patients (<65 years) with suspected coronary artery disease (CAD).
- The utility of coronary CTA in older populations (≥65 years) with suspected CAD is less established due to higher CAD prevalence.
Purpose of the Study:
- To evaluate the diagnostic yield and prognostic significance of coronary CTA across different age groups.
- To assess the association between coronary CTA findings (CAD severity and extent) and major adverse cardiovascular events (MACE) in patients <65 and ≥65 years.
Main Methods:
- Retrospective analysis of 22,412 patients referred for coronary CTA (2006-2021).
- Exclusion criteria included prior CAD, severe renal disease, and malignancy.
- Cox regression models assessed the link between CAD severity/extent and MACE (cardiovascular death, myocardial infarction, ischemic stroke) stratified by age (<65 vs. ≥65 years).
Main Results:
- Older patients (≥65 years) exhibited higher rates of obstructive CAD (38% vs. 15%) and extensive plaque (52% vs. 20%) compared to younger patients (<65 years).
- Obstructive CAD was significantly associated with MACE in both age groups (HR: 2.45, P<0.001 for <65; HR: 1.97, P<0.001 for ≥65).
- Nonobstructive plaque predicted MACE in younger patients (HR: 1.39, P=0.005), while extensive nonobstructive plaque predicted MACE in older patients (HR: 1.56, P=0.02).
Conclusions:
- Coronary CTA effectively identifies significant CAD in older adults, with higher prevalence of obstructive disease and extensive plaque.
- While obstructive CAD and extensive nonobstructive plaque are linked to MACE in older adults, the prognostic value of nonobstructive plaque alone is limited.
- Improved risk stratification tools for nonobstructive plaque could enhance coronary CTA's value, particularly in elderly patients.
Background:
Recent guidelines suggest that coronary computed tomography angiography (CTA) may be the preferred testing modality in patients <65 years of age who are suspected of having coronary artery disease (CAD). Because of a higher prevalence of CAD, the role of coronary CTA in older cohorts is less well established.
Objectives:
The authors aimed to characterize the yield and prognostic utility of coronary CTA by age in a large registry with long-term follow-up.
Methods:
Retrospective cohort of patients clinically referred to coronary CTA at 2 medical centers from 2006 to 2021, excluding patients with prior CAD, severe renal disease, and malignancy. Adjusted Cox regression was used to assess the association of CAD severity (absent, nonobstructive, obstructive) and extent (number of vessels with plaque) with adverse cardiovascular events (major adverse cardiovascular events [MACE]: cardiovascular death, nonfatal myocardial infarction, or ischemic stroke) across different age groups.
Results:
Among 22,412 patients followed over a median of 6.2 years (Q1-Q3: 3.9-9.6 years), 16,726 were <65 years of age and 5,686 were ≥65 years of age. Older patients had a higher prevalence of obstructive CAD (38% vs 15%) and extensive plaque (52% vs 20% with 3- to 4-vessel involvement) compared with their younger counterparts. Nonobstructive plaque was common in both groups (<65 years of age: 37%; ≥65 years of age: 48%). Obstructive CAD was associated with MACE in both younger (HR: 2.45; P < 0.001) and older individuals (HR: 1.97; P < 0.001). Nonobstructive plaque was associated with MACE in younger individuals (HR: 1.39; P = 0.005), whereas only extensive nonobstructive CAD was associated with MACE in older individuals (HR: 1.56; P = 0.02). Among those with obstructive CAD on coronary CTA who underwent early invasive coronary angiography, revascularization was less common among older adults (48% vs 56%; P = 0.002).
Conclusions:
In a large coronary CTA registry, patients ≥65 years of age were more likely to have extensive plaque and stenosis. Although the prognostic value of coronary CTA may be lower among older adults with nonobstructive plaque (a group that has a similar event rate as those with no CAD), the presence of extensive nonobstructive plaque or obstructive stenosis was independently associated with a significantly higher rate of MACE. Newer techniques to better risk stratify patients with nonobstructive plaque may improve the value of coronary CTA, especially in older adults.
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