Risk Reclassification With Coronary Computed Tomography Angiography-Visualized Nonobstructive Coronary Artery Disease According to 2018 American College of Cardiology/American Heart Association Cholesterol Guidelines (from the Coronary Computed Tomography Angiography Evaluation for Clinical Outcomes : An International Multicenter Registry [CONFIRM])


Donghee Han, New York Presbyterian Hospital
Ashley Beecy, New York Presbyterian Hospital
Khalil Anchouche, New York Presbyterian Hospital
Heidi Gransar, Cedars-Sinai Medical Center
Patricia C. Dunham, New York Presbyterian Hospital
Ji Hyun Lee, New York Presbyterian Hospital
Stephan Achenbach, Friedrich-Alexander-Universität Erlangen-Nürnberg
Mouaz H. Al-Mallah, Methodist Hospital Houston
Daniele Andreini, IRCCS Centro Cardiologico Monzino
Daniel S. Berman, Cedars-Sinai Medical Center
Jeroen J. Bax, Leiden University Medical Center - LUMC
Matthew J. Budoff, The Lundquist Institute
Filippo Cademartiri, IRCCS Fondazione SDN
Tracy Q. Callister, Tennessee Heart and Vascular Institute
Hyuk Jae Chang, Severance Hospital
Kavitha Chinnaiyan, William Beaumont Hospital
Benjamin J.W. Chow, University of Ottawa, Canada
Ricardo C. Cury, Baptist Cardiac and Vascular Institute
Augustin DeLago, Capitol Cardiology Associates
Gudrun Feuchtner, Medizinische Universitat Innsbruck
Martin Hadamitzky, Deutsches Herzzentrum München
Joerg Hausleiter, Ludwig-Maximilians-Universität München
Philipp A. Kaufmann, UniversitatsSpital Zurich
Yong Jin Kim, Seoul National University Hospital
Jonathon A. Leipsic, The University of British Columbia
Erica Maffei
Hugo Marques, Hospital da Luz
Pedro de Araújo Gonçalves, Hospital da Luz
Gianluca Pontone, IRCCS Centro Cardiologico Monzino
Gilbert L. Raff, William Beaumont Hospital
Ronen Rubinshtein, Technion - Israel Institute of Technology
Todd C. Villines, University of Virginia Health System
Yao Lu, New York Presbyterian Hospital

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American Journal of Cardiology


© 2019 The 2018 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol management guideline recommends risk enhancers in the borderline-risk and statin recommended/intermediate-risk groups. We determined the risk reclassification by the presence and severity of coronary computed tomography angiography (CCTA)-visualized coronary artery disease (CAD) according to statin eligibility groups. Of 35,281 individuals who underwent CCTA, 1,303 asymptomatic patients (age 59, 65% male) were identified. Patients were categorized as low risk, borderline risk, statin recommended/intermediate risk or statin recommended/high risk according to the guideline. CCTA-visualized CAD was categorized as no CAD, nonobstructive, or obstructive. Major adverse cardiovascular events (MACE) were defined as a composite outcome of all-cause mortality, nonfatal myocardial infarction, and late coronary revascularization (>90 days). We tested a reclassification wherein no CAD reclassifies downward, and the presence of any CAD reclassifies upward. During a median follow-up of 2.9 years, 93 MACE events (7.1%) were observed. Among the borderline-risk and statin-recommended/intermediate-risk groups eligible for risk enhancers, the presence or absence of any CCTA-visualized CAD led to a net increase of 2.3% of cases and 22.4% of controls correctly classified (net reclassification index [NRI] 0.27, 95% CI 0.13 to 0.41, p = 0.0002). The NRI was not significant among low- or statin-recommended/high-risk patients (all p >0.05). The presence or absence of CCTA-visualized CAD, including both obstructive and nonobstructive CAD, significantly improves reclassification in patients eligible for risk enhancers in 2018 ACC/AHA guidelines. Patients in low- and high-risk groups derive no significant improvement in risk reclassification from CCTA.





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