Min James K, Labounty Troy M, Gomez Millie J, Achenbach Stephan, Al-Mallah Mouaz, Budoff Matthew J, Cademartiri Filippo, Callister Tracy Q, Chang Hyuk-Jae, Cheng Victor, Chinnaiyan Kavitha M, Chow Benjamin, Cury Ricardo, Delago Augustin, Dunning Allison, Feuchtner Gudrun, Hadamitzky Martin, Hausleiter Jorg, Kaufmann Philipp, Kim Yong-Jin, Leipsic Jonathon, Lin Fay Y, Maffei Erica, Raff Gilbert, Shaw Leslee J, Villines Todd C, Berman Daniel S
Department of Radiology, Weill Cornell Medical College and The NewYork-Presbyterian Hospital, New York, NY, USA.
Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
Atherosclerosis. 2014 Feb;232(2):298-304. doi: 10.1016/j.atherosclerosis.2013.09.025. Epub 2013 Oct 29.
Coronary artery disease (CAD) diagnosis by coronary computed tomographic angiography (CCTA) is useful for identification of symptomatic diabetic individuals at heightened risk for death. Whether CCTA-detected CAD enables improved risk assessment of asymptomatic diabetic individuals beyond clinical risk factors and coronary artery calcium scoring (CACS) remains unexplored.
From a prospective 12-center international registry of 27,125 individuals undergoing CCTA, we identified 400 asymptomatic diabetic individuals without known CAD. Coronary stenosis by CCTA was graded as 0%, 1-49%, 50-69%, and ≥70%. CAD was judged on a per-patient, per-vessel and per-segment basis as maximal stenosis severity, number of vessels with ≥50% stenosis, and coronary segments weighted for stenosis severity (segment stenosis score), respectively. We assessed major adverse cardiovascular events (MACE) - inclusive of mortality, nonfatal myocardial infarction (MI), and late target vessel revascularization ≥90 days (REV) - and evaluated the incremental utility of CCTA for risk prediction, discrimination and reclassification.
Mean age was 60.4 ± 9.9 years; 65.0% were male. At a mean follow-up 2.4 ± 1.1 years, 33 MACE occurred (13 deaths, 8 MI, 12 REV) [8.25%; annualized rate 3.4%]. By univariate analysis, per-patient maximal stenosis [hazards ratio (HR) 2.24 per stenosis grade, 95% confidence interval (CI) 1.61-3.10, p < 0.001], increasing numbers of obstructive vessels (HR 2.30 per vessel, 95% CI 1.75-3.03, p < 0.001) and segment stenosis score (HR 1.14 per segment, 95% CI 1.09-1.19, p < 0.001) were associated with increased MACE. After adjustment for CAD risk factors and CACS, maximal stenosis (HR 1.80 per grade, 95% CI 1.18-2.75, p = 0.006), number of obstructive vessels (HR 1.85 per vessel, 95% CI 1.29-2.65, p < 0.001) and segment stenosis score (HR 1.11 per segment, 95% CI 1.05-1.18, p < 0.001) were associated with increased risk of MACE. Beyond age, gender and CACS (C-index 0.64), CCTA improved discrimination by maximal stenosis, number of obstructive vessels and segment stenosis score (C-index 0.77, 0.77 and 0.78, respectively). Similarly, CCTA findings improved risk reclassification by per-patient maximal stenosis [integrated discrimination improvement (IDI) index 0.03, p = 0.03] and number of obstructive vessels (IDI index 0.06, p = 0.002), and by trend for segment stenosis score (IDI 0.03, p = 0.06).
For asymptomatic diabetic individuals, CCTA measures of CAD severity confer incremental risk prediction, discrimination and reclassification on a per-patient, per-vessel and per-segment basis.
通过冠状动脉计算机断层血管造影（CCTA）诊断冠状动脉疾病（CAD）有助于识别有症状的糖尿病个体中死亡风险较高者。CCTA检测到的CAD是否能在临床危险因素和冠状动脉钙化评分（CACS）之外，改善无症状糖尿病个体的风险评估，目前尚不清楚。
在一项对27125例接受CCTA检查的个体进行的前瞻性12中心国际登记研究中，我们识别出400例无已知CAD的无症状糖尿病个体。CCTA显示的冠状动脉狭窄程度分为0%、1%-49%、50%-69%和≥70%。CAD分别根据每位患者、每支血管和每段血管的最大狭窄严重程度、狭窄≥50%的血管数量以及根据狭窄严重程度加权的冠状动脉节段（节段狭窄评分）进行判断。我们评估了主要不良心血管事件（MACE），包括死亡、非致命性心肌梗死（MI）和≥90天的晚期靶血管血运重建（REV），并评估了CCTA在风险预测、鉴别和重新分类方面的增量效用。
平均年龄为60.4±9.9岁；65.0%为男性。平均随访2.4±1.1年，发生了33例MACE（13例死亡、8例MI、12例REV）[8.25%；年化率3.4%]。单因素分析显示，每位患者的最大狭窄程度[每增加一个狭窄等级，风险比（HR）为2.24，95%置信区间（CI）为1.61-3.10，p<0.001]、阻塞性血管数量增加（每增加一支血管，HR为2.30，95%CI为1.75-3.03，p<
