The Coronary Artery Disease–Reporting and Data System (CAD-RADS): Prognostic and Clinical Implications Associated With Standardized Coronary Computed Tomography Angiography Reporting


Joe X. Xie, Emory University School of Medicine
Ricardo C. Cury, Baptist Cardiac and Vascular Institute
Jonathon Leipsic, The University of British Columbia
Matthew T. Crim, Emory University School of Medicine
Daniel S. Berman, Cedars-Sinai Medical Center
Heidi Gransar, Cedars-Sinai Medical Center
Matthew J. Budoff, David Geffen School of Medicine at UCLA
Stephan Achenbach, Friedrich-Alexander-Universität Erlangen-Nürnberg
Bríain Ó Hartaigh, Weill Cornell Medicine
Tracy Q. Callister, Division of Cardiology, Tennessee Heart and Vascular Institute
Hugo Marques, Hospital da Luz
Ronen Rubinshtein, Technion - Israel Institute of Technology
Mouaz H. Al-Mallah, Henry Ford Hospital
Daniele Andreini, Università degli Studi di Milano
Gianluca Pontone, Università degli Studi di Milano
Filippo Cademartiri, Institut de Cardiologie de Montreal
Erica Maffei, Institut de Cardiologie de Montreal
Kavitha Chinnaiyan, William Beaumont Hospital
Gilbert Raff, William Beaumont Hospital
Martin Hadamitzky, Deutsches Herzzentrum München
Joerg Hausleiter, Ludwig-Maximilians-Universität München
Gudrun Feuchtner, Medizinische Universitat Innsbruck
Allison Dunning, Duke Clinical Research Institute
Augustin DeLago, Capitol Cardiology Associates
Yong Jin Kim, Seoul National University Hospital
Philipp A. Kaufmann, UniversitatsSpital Zurich
Todd C. Villines, Walter Reed National Military Medical Center
Benjamin J.W. Chow, University of Ottawa Heart Institute
Niree Hindoyan, Weill Cornell Medicine
Millie Gomez, Weill Cornell Medicine
Fay Y. Lin, Weill Cornell Medicine
Erica Jones, Weill Cornell Medicine
James K. Min, Weill Cornell Medicine

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JACC: Cardiovascular Imaging


© 2018 American College of Cardiology Foundation Objectives This study sought to assess clinical outcomes associated with the novel Coronary Artery Disease–Reporting and Data System (CAD-RADS) scores used to standardize coronary computed tomography angiography (CTA) reporting and their potential utility in guiding post-coronary CTA care. Background Clinical decision support is a major focus of health care policies aimed at improving guideline-directed care. Recently, CAD-RADS was developed to standardize coronary CTA reporting and includes clinical recommendations to facilitate patient management after coronary CTA. Methods In the multinational CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry, 5,039 patients without known coronary artery disease (CAD) underwent coronary CTA and were stratified by CAD-RADS scores, which rank CAD stenosis severity as 0 (0%), 1 (1% to 24%), 2 (25% to 49%), 3 (50% to 69%), 4A (70% to 99% in 1 to 2 vessels), 4B (70% to 99% in 3 vessels or ≥50% left main), or 5 (100%). Kaplan-Meier and multivariable Cox models were used to estimate all-cause mortality or myocardial infarction (MI). Receiver-operating characteristic (ROC) curves were used to compare CAD-RADS to the Duke CAD Index and traditional CAD classification. Referrals to invasive coronary angiography (ICA) after coronary CTA were also assessed. Results Cumulative 5-year event-free survival ranged from 95.2% to 69.3% for CAD-RADS 0 to 5 (p < 0.0001). Higher scores were associated with elevations in event risk (hazard ratio: 2.46 to 6.09; p < 0.0001). The ROC curve for prediction of death or MI was 0.7052 for CAD-RADS, which was noninferior to the Duke Index (0.7073; p = 0.893) and traditional CAD classification (0.7095; p = 0.783). ICA rates were 13% for CAD-RADS 0 to 2, 66% for CAD-RADS 3, and 84% for CAD-RADS ≥4A. For CAD-RADS 3, 58% of all catheterizations occurred within the first 30 days of follow-up. In a patient subset with available medication data, 57% of CAD-RADS 3 patients who received 30-day ICA were either asymptomatic or not receiving antianginal therapy at baseline, whereas only 32% had angina and were receiving medical therapy. Conclusions CAD-RADS effectively identified patients at risk for adverse events. Frequent ICA use was observed among patients without severe CAD, many of whom were asymptomatic or not taking antianginal drugs. Incorporating CAD-RADS into coronary CTA reports may provide a novel opportunity to promote evidence-based care post-coronary CTA.





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