Prognostic Value of Combined CT Angiography and Myocardial Perfusion Imaging versus Invasive Coronary Angiography and Nuclear Stress Perfusion Imaging in the Prediction of Major Adverse Cardiovascular Events: The CORE320 Multicenter Study

Abstract

Purpose To compare the prognostic importance (time to major adverse cardiovascular event [MACE]) of combined computed tomography (CT) angiography and CT myocardial stress perfusion imaging with that of combined invasive coronary angiography (ICA) and stress single photon emission CT myocardial perfusion imaging. Materials and Methods This study was approved by all institutional review boards, and written informed consent was obtained. Between November 2009 and July 2011, 381 participants clinically referred for ICA and aged 45-85 years were enrolled in the Combined Noninvasive Coronary Angiography and Myocardial Perfusion Imaging Using 320-Detector Row Computed Tomography (CORE320) prospective multicenter diagnostic study. All images were analyzed in blinded independent core laboratories, and a panel of physicians adjudicated all adverse events. MACE was defined as revascularization (>30 days after index ICA), myocardial infarction, or cardiac death; hospitalization for chest pain or congestive heart failure; or arrhythmia. Late MACE was defined similarly, except for patients who underwent revascularization within the first 182 days after ICA, who were excluded. Comparisons of 2-year survival (time to MACE) used standard Kaplan-Meier curves and restricted mean survival times bootstrapped with 2000 replicates. Results An MACE (49 revascularizations, five myocardial infarctions, one cardiac death, nine hospitalizations for chest pain or congestive heart failure, and one arrhythmia) occurred in 51 of 379 patients (13.5%). The 2-year MACE-free rates for combined CT angiography and CT perfusion findings were 94% negative for coronary artery disease (CAD) versus 82% positive for CAD and were similar to combined ICA and single photon emission CT findings (93% negative for CAD vs 77% positive for CAD, P < .001 for both). Event-free rates for CT angiography and CT perfusion versus ICA and single photon emission CT for either positive or negative results were not significantly different for MACE or late MACE (P > .05 for all). The area under the receiver operating characteristic curve (AUC) for combined CT angiography and CT perfusion (AUC = 68; 95% confidence interval [CI]: 62, 75) was similar (P = .36) to that for combined ICA and single photon emission CT (AUC = 71; 95% CI: 65, 79) in the identification of MACE at 2-year follow-up. Conclusion Combined CT angiography and CT perfusion enables similar prediction of 2-year MACE, late MACE, and event-free survival similar to that enabled by ICA and single photon emission CT. ^© RSNA, 2017 Online supplemental material is available for this article.

Figure 1:

Kaplan-Meier survival curves used to predict MACE (composite end point of late revascularization [>30 days], myocardial infarction, cardiac death, arrhythmia, and hospitalization for chest pain or congestive heart failure) and late MACE (composite end point of late revascularization [>182 days], myocardial infarction, cardiac death, arrhythmia, and hospitalization for chest pain or congestive heart failure) at 2 years after index cardiac catheterization. A, MACE survival curves for patients with and those without hemodynamically obstructive CAD at combined CT angiography and CT perfusion (CTA /CTP) and combined ICA and single photon emission CT (ICA /SPECT ). Significant differences in event-free survival were noted between patients with and those without hemodynamically obstructive coronary artery stenosis at both combined CT angiography and CT perfusion and combined ICA and single photon emission CT (P < .001). However, although no significant difference was found in the ability of combined CT angiography and CT perfusion to help us predict event-free survival in patients without hemodynamically obstructive coronary artery stenoses when compared with combined ICA and single photon emission CT (P = .42), in patients with obstructive lesions, differences significantly favored the combination of ICA and single photon emission CT (P = .047). B, Late MACE survival curves in patients with and in those without hemodynamically obstructive CAD at CT angiography and CT perfusion and at ICA and single photon emission CT. Significant differences in event-free survival were noted between patients with and those without hemodynamically obstructive coronary artery stenosis at combined CT angiography and CT perfusion and at combined ICA and single photon emission CT (P < .01). However, although no significant difference was found in the ability of combined CT angiography and CT perfusion to enable us predict event-free survival in patients without hemodynamically obstructive coronary artery stenoses when compared with combined ICA and single photon emission CT (P = .62), for those with obstructive lesions differences were of borderline significance and favored the combination of ICA and single photon emission CT (P = .098).

Figure 2:

Kaplan-Meier survival curves used to predict MACE (composite end point of late revascularization [>30 days], myocardial infarction, cardiac death, arrhythmia, and hospitalization for chest pain or congestive heart failure) and late MACE (composite end point of late revascularization [>182 days], myocardial infarction, cardiac death, arrhythmia, and hospitalization for chest pain or congestive heart failure) at 2 years after index cardiac catheterization. A, Survival curves for combined CT angiography and CT perfusion in patients without hemodynamically obstructive CAD and in those with one, two, or three vessels with hemodynamically obstructive CAD. B, Survival curves for combined ICA and single photon emission CT myocardial perfusion in patients without hemodynamically obstructive CAD and in those with one, two, or three vessels with hemodynamically obstructive CAD. C, Survival curves for combined CT angiography and myocardial perfusion in patients without hemodynamically obstructive CAD and in those with one, two, or three vessels with hemodynamically obstructive CAD. D, Survival curves for combined ICA and single photon emission CT myocardial perfusion in patients without hemodynamically obstructive CAD and in those with one, two, or three vessels with hemodynamically obstructive CAD.

Figure 3:

Receiver operating characteristic curves for combined CT angiography and myocardial perfusion imaging (CTA+CTP) and combined ICA and single photon emission computed tomography (ICA+SPECT ) used to predict, A, MACE (composite end point of late revascularization [>30 days], myocardial infarction, cardiac death, arrhythmia, or hospitalization for chest pain or congestive heart failure) at 2-year follow-up or, B, late MACE (composite end point of late revascularization [>182 days], myocardial infarction, cardiac death, arrhythmia, or hospitalization for chest pain or congestive heart failure) at 2-year follow-up.