Division of Cardiology, Severance Cardiovascular Hospital, Seoul, South Korea.
Circulation. 2012 Jul 17;126(3):304-13. doi: 10.1161/CIRCULATIONAHA.111.081380. Epub 2012 Jun 9.
The predictive value of coronary computed tomographic angiography (cCTA) in subjects without chest pain syndrome (CPS) has not been established. We investigated the prognostic value of coronary artery disease detection by cCTA and determined the incremental risk stratification benefit of cCTA findings compared with clinical risk factor scoring and coronary artery calcium scoring (CACS) for individuals without CPS.
An open-label, 12-center, 6-country observational registry of 27 125 consecutive patients undergoing cCTA and CACS was queried, and 7590 individuals without CPS or history of coronary artery disease met the inclusion criteria. All-cause mortality and the composite of all-cause mortality and nonfatal myocardial infarction were measured. During a median follow-up of 24 months (interquartile range, 18-35 months), all-cause mortality occurred in 136 individuals. After risk adjustment, compared with individuals without evidence of coronary artery disease by cCTA, individuals with obstructive 2- and 3-vessel disease or left main coronary artery disease experienced higher rates of death and composite outcome (P<0.05 for both). Both CACS and cCTA significantly improved the performance of standard risk factor prediction models for all-cause mortality and the composite outcome (likelihood ratio P<0.05 for all), but the incremental discriminatory value associated with their inclusion was more pronounced for the composite outcome and for CACS (C statistic for model with risk factors only was 0.71; for risk factors plus CACS, 0.75; for risk factors plus CACS plus cCTA, 0.77). The net reclassification improvement resulting from the addition of cCTA to a model based on standard risk factors and CACS was negligible.
Although the prognosis for individuals without CPS is stratified by cCTA, the additional risk-predictive advantage by cCTA is not clinically meaningful compared with a risk model based on CACS. Therefore, at present, the application of cCTA for risk assessment of individuals without CPS should not be justified.
在无胸痛综合征（CPS）患者中，冠状动脉计算机断层血管造影（cCTA）的预测价值尚未确定。我们研究了 cCTA 检测冠状动脉疾病的预后价值，并确定了与临床危险因素评分和冠状动脉钙评分（CACS）相比，cCTA 结果对无 CPS 个体进行增量风险分层的益处。
一项开放标签、12 中心、6 个国家的连续 27125 例患者行 cCTA 和 CACS 的观察性登记研究进行了查询，7590 例无 CPS 或冠心病病史的个体符合纳入标准。测量全因死亡率和全因死亡率和非致死性心肌梗死的复合终点。在中位数为 24 个月（四分位距 18-35 个月）的随访期间，136 例患者发生全因死亡。在风险调整后，与 cCTA 无冠状动脉疾病证据的个体相比，存在 2 支和 3 支血管疾病或左主干冠状动脉疾病的个体死亡和复合结局发生率更高（两者 P<0.05）。CACS 和 cCTA 均显著提高了标准危险因素预测模型对全因死亡率和复合结局的预测性能（似然比 P<0.05），但纳入 CACS 和 cCTA 后与风险相关的增量判别值更显著结果和 CACS（仅危险因素模型的 C 统计量为 0.71；危险因素加 CACS，0.75；危险因素加 CACS 加 cCTA，0.77）。从标准危险因素和 CACS 模型中添加 cCTA 导致的净重新分类改善微不足道。
尽管无 CPS 个体的预后可以通过 cCTA 分层，但与基于 CACS 的风险模型相比，cCTA 提供的额外风险预测优势在临床上并无意义。因此，目前，cCTA 用于无 CPS 个体的风险评估的应用不应得到证明。
