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]) - 15/10/19

Doi : 10.1016/j.amjcard.2019.07.045

Donghee Han, MD ^a,^b,^c, Ashley Beecy, MD ^a, Khalil Anchouche, MD ^a, Heidi Gransar, MSc ^c, Patricia C. Dunham, BS ^a, Ji-Hyun Lee, MD ^a,^b,^d, Stephan Achenbach, MD ^e, Mouaz H. Al-Mallah, MD ^f, Daniele Andreini, MD, PhD ^g, Daniel S. Berman, MD ^h, Jeroen J. Bax, MD, PhD ⁱ, Matthew J. Budoff, MD ^j, Filippo Cademartiri, MD, PhD ^k, Tracy Q. Callister, MD ^l, Hyuk-Jae Chang, MD, PhD ^b, Kavitha Chinnaiyan, MD ^m, Benjamin J.W. Chow, MD ⁿ, Ricardo C. Cury, MD ^o, Augustin DeLago, MD ^p, Gudrun Feuchtner, MD ^q, Martin Hadamitzky, MD ^r, Joerg Hausleiter, MD ^s, Philipp A. Kaufmann, MD ^t, Yong-Jin Kim, MD, PhD ^u, Jonathon A. Leipsic, MD ^v, Erica Maffei, MD ^w, Hugo Marques, MD, PhD ^x, Pedro de Araújo Gonçalves, MD, PhD ^x, Gianluca Pontone, MD, PhD ^g, Gilbert L. Raff, MD ^m, Ronen Rubinshtein, MD ^y, Todd C. Villines, MD ^z, Yao Lu, MSc ^aa, Jessica M. Peña, MD ^a, Leslee J. Shaw, PhD ^a, James K. Min, MD ^a, Fay Y. Lin, MD ^a,^⁎
^a Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York
^b Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Republic of Korea
^c Department of Imaging, Cedars Sinai Medical Center, Los Angeles, California
^d Department of Cardiology, Myongji Hospital, Goyang-si, South Korea
^e Department of Cardiology, Friedrich-Alexander-University Erlangen-Nuremberg, Germany
^f Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
^g Centro Cardiologico Monzino, IRCCS Milan, Italy
^h Department of Imaging and Medicine, Cedars Sinai Medical Center, Los Angeles, California
ⁱ Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
^j Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, California
^k Cardiovascular Imaging Center, SDN IRCCS, Naples, Italy
^l Tennessee Heart and Vascular Institute, Hendersonville, Tennessee
^m Department of Cardiology, William Beaumont Hospital, Royal Oak, Michigan
ⁿ Department of Medicine and Radiology, University of Ottawa, Ontario, Canada
^o Department of Radiology, Miami Cardiac and Vascular Institute, Miami, Florida
^p Capitol Cardiology Associates, Albany, New York
^q Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
^r Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany
^s Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany
^t Department of Nuclear Medicine, University Hospital, Zurich, Switzerland and University of Zurich, Switzerland
^u Department of Internal Medicine, Seoul National University College of Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
^v Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
^w Department of Radiology, Area Vasta 1/ASUR Marche, Urbino, Italy
^x UNICA, Unit of Cardiovascular Imaging, Hospital da Luz, Lisboa, Portugal
^y Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
^z Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
^aa Department of Healthcare Policy and Research, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York

^⁎Corresponding author: Tel: (646) 962-6192.

Riassunto

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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Funding: The research reported in this publication was funded, in part, by the National Institute of Health (Bethesda, MD, USA) under award number R01 HL115150. This research was also supported, in part, by the Dalio Institute of Cardiovascular Imaging (New York, NY, USA) and the Michael Wolk Foundation (New York, NY, USA).

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Vol 124 - N° 9

P. 1397-1405 - novembre 2019 Ritorno al numero

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