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. 2020 May 1;21(5):479-488.
doi: 10.1093/ehjci/jez322.

Clinical risk factors and atherosclerotic plaque extent to define risk for major events in patients without obstructive coronary artery disease: the long-term coronary computed tomography angiography CONFIRM registry

Alexander R van Rosendael  1   2 , A Maxim Bax  1 , Jeff M Smit  2 , Inge J van den Hoogen  1   2 , Xiaoyue Ma  3 , Subhi Al'Aref  1 , Stephan Achenbach  4 , Mouaz H Al-Mallah  5 , Daniele Andreini  6 , Daniel S Berman  7 , Matthew J Budoff  8 , Filippo Cademartiri  9 , Tracy Q Callister  10 , Hyuk-Jae Chang  11 , Kavitha Chinnaiyan  12 , Benjamin J W Chow  13 , Ricardo C Cury  14 , Augustin DeLago  15 , Gudrun Feuchtner  16 , Martin Hadamitzky  17 , Joerg Hausleiter  18 , Philipp A Kaufmann  19 , Yong-Jin Kim  20 , Jonathon A Leipsic  21 , Erica Maffei  22 , Hugo Marques  23 , Pedro de Araújo Gonçalves  23 , Gianluca Pontone  6 , Gilbert L Raff  12 , Ronen Rubinshtein  24 , Todd C Villines  25 , Heidi Gransar  26 , Yao Lu  3 , Jessica M Peña  1 , Fay Y Lin  1 , Leslee J Shaw  1 , James K Min  1 , Jeroen J Bax  2
Affiliations

Clinical risk factors and atherosclerotic plaque extent to define risk for major events in patients without obstructive coronary artery disease: the long-term coronary computed tomography angiography CONFIRM registry

Alexander R van Rosendael et al. Eur Heart J Cardiovasc Imaging. .

Abstract

Aims: In patients without obstructive coronary artery disease (CAD), we examined the prognostic value of risk factors and atherosclerotic extent.

Methods and results: Patients from the long-term CONFIRM registry without prior CAD and without obstructive (≥50%) stenosis were included. Within the groups of normal coronary computed tomography angiography (CCTA) (N = 1849) and non-obstructive CAD (N = 1698), the prognostic value of traditional clinical risk factors and atherosclerotic extent (segment involvement score, SIS) was assessed with Cox models. Major adverse cardiac events (MACE) were defined as all-cause mortality, non-fatal myocardial infarction, or late revascularization. In total, 3547 patients were included (age 57.9 ± 12.1 years, 57.8% male), experiencing 460 MACE during 5.4 years of follow-up. Age, body mass index, hypertension, and diabetes were the clinical variables associated with increased MACE risk, but the magnitude of risk was higher for CCTA defined atherosclerotic extent; adjusted hazard ratio (HR) for SIS >5 was 3.4 (95% confidence interval [CI] 2.3-4.9) while HR for diabetes and hypertension were 1.7 (95% CI 1.3-2.2) and 1.4 (95% CI 1.1-1.7), respectively. Exclusion of revascularization as endpoint did not modify the results. In normal CCTA, presence of ≥1 traditional risk factors did not worsen prognosis (log-rank P = 0.248), while it did in non-obstructive CAD (log-rank P = 0.025). Adjusted for SIS, hypertension and diabetes predicted MACE risk in non-obstructive CAD, while diabetes did not increase risk in absence of CAD (P-interaction = 0.004).

Conclusion: Among patients without obstructive CAD, the extent of CAD provides more prognostic information for MACE than traditional cardiovascular risk factors. An interaction was observed between risk factors and CAD burden, suggesting synergistic effects of both.

Keywords: atherosclerosis; coronary computed tomography angiography; imaging; preventive cardiology; risk stratification.

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Figures

Figure 1
Figure 1
Age and body mass index adjusted hazard ratios are provided for cardiovascular risk factors and the segment involvement score subgroups showing that the number of coronary segments with plaque provide the strongest prognostic information. BMI, body mass index; MI, myocardial infarction; SIS, segment involvement score.
Figure 2
Figure 2
(A) Five-year cumulative MACE-free Kaplan–Meier survival curves among patients without coronary artery disease showing no difference for absence vs. presence of risk factors. (B) Among patients with non-obstructive CAD, MACE-free survival is worse in the presence of cardiovascular risk factors. MACE, major adverse cardiac events.
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