Prognostic value of atherosclerotic burden and coronary vascular function in patients with suspected coronary artery disease

  • Roberta Assante
  • Wanda Acampa
  • Emilia Zampella
  • Parthiban Arumugam
  • Carmela Nappi
  • Valeria Gaudieri
  • Ciro Gabriele Mainolfi
  • Mariarosaria Panico
  • Mario Magliulo
  • Christine M. Tonge
  • Mario Petretta
  • Alberto Cuocolo
Original Article



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.


Coronary artery calcium Coronary flow reserve Hybrid PET/CT Prognosis 


Compliance with ethical standards

Conflict of interest


Ethical approval

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

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • Roberta Assante
    • 1
  • Wanda Acampa
    • 1
    • 2
  • Emilia Zampella
    • 1
  • Parthiban Arumugam
    • 3
  • Carmela Nappi
    • 1
  • Valeria Gaudieri
    • 2
  • Ciro Gabriele Mainolfi
    • 1
  • Mariarosaria Panico
    • 2
  • Mario Magliulo
    • 2
  • Christine M. Tonge
    • 3
  • Mario Petretta
    • 4
  • Alberto Cuocolo
    • 1
  1. 1.Department of Advanced Biomedical SciencesUniversity Federico IINaplesItaly
  2. 2.Institute of Biostructure and Bioimaging, National Council of ResearchNaplesItaly
  3. 3.Nuclear Medicine CenterCentral Manchester University Teaching HospitalsManchesterUK
  4. 4.Department of Translational Medical SciencesUniversity Federico IINaplesItaly

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