Influence of symptom typicality for predicting MACE in patients without obstructive coronary artery disease: From the CONFIRM Registry (Coronary Computed Tomography Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry)

Ji Hyun Lee^{1

2

3}, Donghee Han^{1

2}, Bríain Ó Hartaigh¹, Heidi Gransar³, Yao Lu¹, Asim Rizvi¹, Mahn Won Park¹, Hadi Mirhedayati Roudsari¹, Wijnand J Stuijfzand¹, Daniel S Berman⁴, Tracy Q Callister⁵, Augustin DeLago⁶, Martin Hadamitzky⁷, Joerg Hausleiter⁸, Mouaz H Al-Mallah⁹, Matthew J Budoff¹⁰, Philipp A Kaufmann¹¹, Gilbert Raff¹², Kavitha Chinnaiyan¹², Filippo Cademartiri¹³, Erica Maffei¹⁴, Todd C Villines¹⁵, Yong-Jin Kim¹⁶, Jonathon Leipsic¹⁷, Gudrun Feuchtner¹⁸, Gianluca Pontone¹⁹, Daniele Andreini¹⁹, Hugo Marques²⁰, Ronen Rubinshtein²¹, Stephan Achenbach²², Leslee J Shaw²³, Hyuk-Jae Chang², Jeroen Bax²⁴, Benjamin Chow²⁵, Ricardo C Cury²⁶, Millie Gomez¹, Erica C Jones¹, Fay Y Lin¹, James K Min¹, Jessica M Peña¹

Affiliations

¹ Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York.
² Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea.
³ Division of Cardiology, Department of Internal Medicine, Myongji Hospital, Goyang-si, South Korea.
⁴ Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California.
⁵ Tennessee Heart and Vascular Institute, Hendersonville, Tennessee.
⁶ Capitol Cardiology Associates, Albany, New York.
⁷ Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany.
⁸ Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany.
⁹ King Saud bin Abdulaziz University of Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia.
¹⁰ Department of Medicine, Harbor-UCLA Medical Center, Los Angeles, California.
¹¹ Department of Nuclear Medicine, Cardiac Imaging, University Hospital, Zurich, University of Zurich, Switzerland.
¹² William Beaumont Hospital, Royal, Michigan.
¹³ Cardiovascular Imaging Center, Department of Radiology, SDN IRCCS Naples, Italy.
¹⁴ Department of Radiology, Area Vasta 1/ASUR Marche, Urbino, Italy.
¹⁵ Department of Medicine, Walter Reed Medical Center, Washington, D.C.
¹⁶ Cardiovascular Center and Internal Medicine, Seoul National University Hospital, Seoul, South Korea.
¹⁷ Department of Medicine and Radiology, University of British Columbia, Vancouver, Canada.
¹⁸ Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
¹⁹ Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
²⁰ UNICA, Cardiac CT and MRI Unit, Hospital da Luz, Lisbon, Portugal.
²¹ Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
²² Department of Medicine, University of Erlangen, Erlangen, Germany.
²³ Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
²⁴ Department of Cardiology, Leiden University Medical Center, HARTS, Leiden, The Netherlands.
²⁵ Department of Medicine and Radiology, University of Ottawa, Ontario, Canada.
²⁶ Baptist Cardiac and Vascular Institute, Miami, Florida.

PMID: 29521447
PMCID: PMC6489785
DOI: 10.1002/clc.22940

Observational Study

Influence of symptom typicality for predicting MACE in patients without obstructive coronary artery disease: From the CONFIRM Registry (Coronary Computed Tomography Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry)

Ji Hyun Lee et al. Clin Cardiol. 2018 May.

. 2018 May;41(5):586-593.

doi: 10.1002/clc.22940. Epub 2018 May 11.

Authors

Affiliations

¹ Dalio Institute of Cardiovascular Imaging, Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, New York.
² Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea.
³ Division of Cardiology, Department of Internal Medicine, Myongji Hospital, Goyang-si, South Korea.
⁴ Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California.
⁵ Tennessee Heart and Vascular Institute, Hendersonville, Tennessee.
⁶ Capitol Cardiology Associates, Albany, New York.
⁷ Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany.
⁸ Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany.
⁹ King Saud bin Abdulaziz University of Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia.
¹⁰ Department of Medicine, Harbor-UCLA Medical Center, Los Angeles, California.
¹¹ Department of Nuclear Medicine, Cardiac Imaging, University Hospital, Zurich, University of Zurich, Switzerland.
¹² William Beaumont Hospital, Royal, Michigan.
¹³ Cardiovascular Imaging Center, Department of Radiology, SDN IRCCS Naples, Italy.
¹⁴ Department of Radiology, Area Vasta 1/ASUR Marche, Urbino, Italy.
¹⁵ Department of Medicine, Walter Reed Medical Center, Washington, D.C.
¹⁶ Cardiovascular Center and Internal Medicine, Seoul National University Hospital, Seoul, South Korea.
¹⁷ Department of Medicine and Radiology, University of British Columbia, Vancouver, Canada.
¹⁸ Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
¹⁹ Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
²⁰ UNICA, Cardiac CT and MRI Unit, Hospital da Luz, Lisbon, Portugal.
²¹ Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
²² Department of Medicine, University of Erlangen, Erlangen, Germany.
²³ Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
²⁴ Department of Cardiology, Leiden University Medical Center, HARTS, Leiden, The Netherlands.
²⁵ Department of Medicine and Radiology, University of Ottawa, Ontario, Canada.
²⁶ Baptist Cardiac and Vascular Institute, Miami, Florida.

PMID: 29521447
PMCID: PMC6489785
DOI: 10.1002/clc.22940

Abstract

Our objective was to assess the prognostic value of symptom typicality in patients without obstructive coronary artery disease (CAD), determined by coronary computed tomographic angiography (CCTA). We identified 4215 patients without prior history of CAD and without obstructive CAD (<50% CCTA stenosis). CAD severity was categorized as nonobstructive (1%-49%) and none (0%). Based upon the Diamond-Forrester criteria for angina pectoris, symptom typicality was classified as asymptomatic, nonanginal, atypical, and typical. Multivariable Cox proportional hazards models were used to assess the risk of major adverse cardiac events (MACE), comprising all-cause mortality, myocardial infarction, unstable angina, and late revascularization, according to symptom typicality. Mean patient age was 57.0 ±12.0 years (54.9% male). During a median follow-up of 5.3 years (interquartile range, 4.6-5.9 years), MACE were reported in 312 (7.4%) patients. Among patients with nonobstructive CAD, there was an association between symptom typicality and MACE (P for interaction = 0.05), driven by increased risk of MACE among those with typical angina and nonobstructive CAD (hazard ratio: 1.62, 95% confidence interval: 1.06-2.48, P = 0.03). No consistent relationship was found between symptom typicality and MACE among patients without any CAD (hazard ratio: 0.73, 95% confidence interval: 0.34-1.57, P = 0.08). In the CONFIRM registry, patients who presented with concomitant typical angina and nonobstructive CAD had a higher rate of MACE than did asymptomatic patients with nonobstructive CAD. However, the presence of typical angina did not appear to portend worse prognosis in patients with no CAD.

Keywords: Coronary Artery Disease; Coronary Computed Tomographic Angiography; Major Adverse Cardiac Events; Symptom Typicality.

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Conflict of interest statement

Dr. Min serves on the scientific advisory board of Arineta, has ownership in MDDX, and has a research agreement with GE Healthcare. The authors declare no other potential conflicts of interest.

Figures

**Figure 1**
Incidence of MACE according to symptom typicality and severity of CAD. Abbreviations: CAD, coronary artery disease; MACE, major adverse cardiac events

**Figure 2**
Kaplan–Meier survival curves for time to MACE according to symptom typicality and severity of CAD. Abbreviations: ASX, asymptomatic; ATYP, atypical angina; CAD, coronary artery disease; MACE, major adverse cardiac events; NA, nonanginal; TYP, typical angina

See this image and copyright information in PMC

References

1. Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64‐row CT. N Engl J Med. 2008;359:2324–2336. - PubMed
1. Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64‐multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52:1724–1732. - PubMed
1. Meijboom WB, Meijs MF, Schuijf JD, et al. Diagnostic accuracy of 64‐slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008;52:2135–2144. - PubMed
1. Bittencourt MS, Hulten E, Ghoshhajra B, et al. Prognostic value of nonobstructive and obstructive coronary artery disease detected by coronary computed tomography angiography to identify cardiovascular events. Circ Cardiovasc Imaging. 2014;7:282–291. - PubMed
1. Libby P, Theroux P. Pathophysiology of coronary artery disease. Circulation. 2005;111:3481–3488. - PubMed

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Influence of symptom typicality for predicting MACE in patients without obstructive coronary artery disease: From the CONFIRM Registry (Coronary Computed Tomography Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry)

Affiliations

Influence of symptom typicality for predicting MACE in patients without obstructive coronary artery disease: From the CONFIRM Registry (Coronary Computed Tomography Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry)

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Other Literature Sources

Medical

Miscellaneous