Superior Risk Stratification With Coronary Computed Tomography Angiography Using a Comprehensive Atherosclerotic Risk Score


Alexander R. van Rosendael, Leiden University Medical Center - LUMC
Leslee J. Shaw, Emory University School of Medicine
Joe X. Xie, Emory University School of Medicine
Aukelien C. Dimitriu-Leen, Leiden University Medical Center - LUMC
Jeff M. Smit, Leiden University Medical Center - LUMC
Arthur J. Scholte, Leiden University Medical Center - LUMC
Jacob M. van Werkhoven, Leiden University Medical Center - LUMC
Tracy Q. Callister, Tennessee Heart and Vascular Institute
Augustin DeLago, Capitol Cardiology Associates
Daniel S. Berman, Cedars-Sinai Medical Center
Martin Hadamitzky, Deutsches Herzzentrum München
Jeorg Hausleiter, Deutsches Herzzentrum München
Mouaz H. Al-Mallah, King Saud bin Abdulaziz University for Health Sciences
Matthew J. Budoff, Harbor-UCLA Medical Center
Philipp A. Kaufmann, UniversitatsSpital Zurich
Gilbert Raff, William Beaumont Hospital
Kavitha Chinnaiyan, William Beaumont Hospital
Filippo Cademartiri, IRCCS Fondazione SDN
Erica Maffei
Todd C. Villines, Walter Reed National Military Medical Center
Yong Jin Kim, Seoul National University Hospital
Gudrun Feuchtner, Medizinische Universitat Innsbruck
Fay Y. Lin, New York Presbyterian Hospital
Erica C. Jones, New York Presbyterian Hospital
Gianluca Pontone, Università degli Studi di Milano
Daniele Andreini, Università degli Studi di Milano
Hugo Marques, Hospital da Luz
Ronen Rubinshtein, Technion - Israel Institute of Technology
Stephan Achenbach, Friedrich-Alexander-Universität Erlangen-Nürnberg
Allison Dunning, Duke Clinical Research Institute
Millie Gomez, New York Presbyterian Hospital
Niree Hindoyan, New York Presbyterian Hospital
Heidi Gransar, Cedars-Sinai Medical Center

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JACC: Cardiovascular Imaging


© 2019 American College of Cardiology Foundation 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:





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