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CLINICAL RESEARCH: CARDIAC IMAGING

Prognostic Value of Multidetector Coronary Computed Tomographic Angiography for Prediction of All-Cause Mortality

James K. Min, MD^_*,,_*, Leslee J. Shaw, PhD, Richard B. Devereux, MD^_*, Peter M. Okin, MD^_*, Jonathan W. Weinsaft, MD^_*, Donald J. Russo, MD, Nicholas J. Lippolis, MD, Daniel S. Berman, MD and Tracy Q. Callister, MD

^_* Greenberg Division of Cardiology, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York
Tennessee Heart and Vascular Institute, Hendersonville, Tennessee
Cedars-Sinai Medical Center, Los Angeles, California.

Manuscript received November 7, 2006; revised manuscript received March 5, 2007, accepted March 20, 2007.

^_* Reprint requests and correspondence: Dr. James K. Min, Assistant Professor of Medicine, Division of Cardiology, Department of Medicine, Weill Medical College of Cornell University, New York Presbyterian Hospital, 520 East 70th Street, K415, New York, New York 10021. (Email: jkm2001{at}med.cornell.edu).

Objectives: The purpose of this study was to examine the association of all-cause death with the coronary computed tomographic angiography (CCTA)-defined extent and severity of coronary artery disease (CAD).

Background: The prognostic value of identifying CAD by CCTA remains undefined.

Methods: We examined a single-center consecutive cohort of 1,127 patients 45 years old with chest symptoms. Stenosis by CCTA was scored as minimal (<30%), mild (30% to 49%), moderate (50% to 69%), or severe (70%) for each coronary artery. Plaque was assessed in 3 ways: 1) moderate or obstructive plaque; 2) CCTA score modified from Duke coronary artery score; and 3) simple clinical scores grading plaque extent and distribution. A 15.3 ± 3.9-month follow-up of all-cause death was assessed using Cox proportional hazards models adjusted for pretest CAD likelihood and risk factors. Deaths were verified by the Social Security Death Index.

Results: The CCTA predictors of death included proximal left anterior descending artery stenosis and number of vessels with 50% and 70% stenosis (all p < 0.0001). A modified Duke CAD index, an angiographic score integrating proximal CAD, plaque extent, and left main (LM) disease, improved risk stratification (p < 0.0001). Patients with <50% stenosis had the highest survival at 99.7%. Survival worsened with higher-risk Duke scores, ranging from 96% survival for 1 stenosis 70% or 2 stenoses 50% (p = 0.013) to 85% survival for 50% LM artery stenosis (p < 0.0001). Clinical scores measuring plaque burden and distribution predicted 5% to 6% higher absolute death rate (6.6% vs. 1.6% and 8.4% vs. 2.5%; p = 0.05 for both).

Conclusions: In patients with chest pain, CCTA identifies increased risk for all-cause death. Importantly, a negative CCTA portends an extremely low risk for death.

Abbreviations and Acronyms   CAD = coronary artery disease   CCTA = coronary computed tomographic angiography

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