Prognostic value of atherosclerotic burden and coronary vascular function in patients with suspected coronary artery disease
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To evaluate the prognostic value of coronary atherosclerotic burden, assessed by coronary artery calcium (CAC) score, and coronary vascular function, assessed by coronary flow reserve (CFR) in patients with suspected coronary artery disease (CAD).
We studied 436 patients undergoing hybrid 82Rb positron emission tomography/computed tomography imaging. CAC score was measured according to the Agatston method, and patients were categorized into three groups (0, <400, and ≥400). CFR was calculated as the ratio of hyperemic to baseline myocardial blood flow, and it was considered reduced when <2.
Follow-up was 94% complete during a mean period of 47±15 months. During follow-up, 17 events occurred (4% cumulative event rate). Event-free survival decreased with worsening of CAC score category (p < 0.001) and in patients with reduced CFR (p < 0.005). At multivariable analysis, CAC score ≥400 (p < 0.01) and CFR (p < 0.005) were independent predictors of events. Including CFR in the prognostic model, continuous net reclassification improvement was 0.51 (0.14 in patients with events and 0.37 in those without). At classification and regression tree analysis, the initial split was on CAC score. For patients with a CAC score < 400, no further split was performed, while patients with a CAC score ≥400 were further stratified by CFR values. Decision curve analyses indicate that the model including CFR resulted in a higher net benefit across a wide range of decision threshold probabilities.
In patients with suspected CAD, CFR provides significant incremental risk stratification over established cardiac risk factors and CAC score for prediction of adverse cardiac events.
KeywordsCoronary artery calcium Coronary flow reserve Hybrid PET/CT Prognosis
Compliance with ethical standards
Conflict of interest
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
- 1.Berman DS, Hachamovitch R, Shaw LJ, Friedman JD, Hayes SW, Thomson LE, et al. Roles of nuclear cardiology, cardiac computed tomography, and cardiac magnetic resonance: Noninvasive risk stratification and a conceptual framework for the selection of noninvasive imaging tests in patients with known or suspected coronary artery disease. J Nucl Med. 2006;47:1107–18.PubMedGoogle Scholar
- 2.Lee H, Yoon YE, Park JB, Kim HL, Park HE, Lee SP, et al. The incremental prognostic value of cardiac computed tomography in comparison with single-photon emission computed tomography in patients with suspected coronary artery disease. PLoS One. 2016;11:e0160188.CrossRefPubMedPubMedCentralGoogle Scholar
- 3.Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, et al. American College of Cardiology Foundation, American Heart Association. ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2010;2010:e50–103.CrossRefGoogle Scholar
- 7.Taqueti VR, Hachamovitch R, Murthy VL, Naya M, Foster CR, Hainer J, et al. Global coronary flow reserve is associated with adverse cardiovascular events independently of luminal angiographic severity and modifies the effect of early revascularization. Circulation. 2015;131:19–27.CrossRefPubMedGoogle Scholar
- 9.Danad I, Raijmakers PG, Appelman YE, Harms HJ, de Haan S, Marques KM, et al. Quantitative relationship between coronary artery calcium score and hyperemic myocardial blood flow as assessed by hybrid 15O-water PET/CT imaging in patients evaluated for coronary artery disease. J Nucl Cardiol. 2012;19:256–64.CrossRefPubMedGoogle Scholar
- 10.Assante R, Zampella E, Arumugam P, Acampa W, Imbriaco M, Tout D, et al. Quantitative relationship between coronary artery calcium and myocardial blood flow by hybrid rubidium-82 PET/CT imaging in patients with suspected coronary artery disease. J Nucl Cardiol. 2017;24:494–501.CrossRefPubMedGoogle Scholar
- 11.Rosendorff C, Black HR, Cannon CP, Gersh BJ, Gore J, Izzo JL Jr, et al. Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation. 2007;115:2761–88.CrossRefPubMedGoogle Scholar
- 12.Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation. 2002;105:539–42.CrossRefPubMedGoogle Scholar
- 18.Newson R. Comparing the predictive powers of survival models using Harrell’s C or Somers’ D. Stata J. 2010;10:339–58.Google Scholar
- 19.van Putten W. Classification and regression tree analysis with Stata. http://www.stata.com/meeting/2dutch/cart.pdf.