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. 2025 Nov 9:e2521077.
doi: 10.1001/jama.2025.21077. Online ahead of print.

Coronary Computed Tomography Angiography in Prediction of First Coronary Events

Göran Bergström  1   2 , Gunnar Engström  3 , Elias Björnson  1 , Martin Adiels  4 , Jonas S O Andersson  5 , Therese Andersson  6 , Carl-Johan Carlhäll  7   8 , Kerstin Cederlund  9 , David Erlinge  10 , Erika Fagman  11   12 , Elin Good  8   13 , Anders Gummesson  1   14 , Emil Hagström  15 , Stefan James  15 , Magnus Janzon  13 , Ioannis Katsoularis  6 , Jeanette Kuhl  16 , Henrik Löfmark  16 , Hanna Markstad  3   17 , Jonas Oldgren  15 , Viktor Oskarsson  18 , Ellen Ostenfeld  19 , Anders Persson  8   20   21 , Adrian Pistea  17   22 , Annika Rosengren  1   23 , Jonas Spaak  16 , Johan Sundström  24   25 , Stefan Söderberg  6 , Erik Thunström  1   26 , Carl Johan Östgren  8   27 , Lars Lind  28 , Tomas Jernberg  16
Affiliations

Coronary Computed Tomography Angiography in Prediction of First Coronary Events

Göran Bergström et al. JAMA. .

Abstract

Importance: Risk stratification strategies in primary prevention of coronary events lack precision.

Objective: To determine whether prediction of first coronary events is improved by adding information on coronary atherosclerosis from coronary computed tomography angiography (CCTA) to a model using the pooled cohort equation (PCE) risk score tool and the coronary artery calcification score (CACS).

Design, setting, and participants: Observational cohort study including individuals aged 50 to 64 years randomly recruited from the general population and examined at 6 university hospitals in Sweden from 2013 to 2018, with a median follow-up of 7.8 years. A sample of 30 154 individuals underwent cardiopulmonary imaging, physical examinations, routine laboratory tests, questionnaires, and/or functional tests. This study included 24 791 individuals without previous cardiovascular disease for whom high-quality CCTA images were available. Events were followed up via registers until September 2024.

Exposures: The information used from the CCTA images was the extent of coronary atherosclerosis (segment involvement score), presence of noncalcified atherosclerosis, and presence of coronary obstructive disease (stenosis ≥50%).

Main outcomes and measures: The outcome was a composite of first occurrence of nonfatal myocardial infarction or death from coronary heart disease.

Results: During follow-up, 304 coronary events occurred. Segment involvement scores of 3 to 4 and greater than 4 and presence of noncalcified atherosclerosis were associated with hazard ratios of 2.71 (95% CI, 1.34-5.44), 5.27 (95% CI, 2.50-11.07), and 1.66 (95% CI, 1.23-2.22), respectively. In a model based on the PCE and CACS, CCTA-derived data improved risk discrimination (C statistic improved from 0.764 to 0.779; P = .004) and risk reclassification (net reclassification improvement of 0.133 [95% CI, 0.031-0.165]), conferred a net correct upward reclassification of 14.2% in those with events and incorrectly classified 1.6% of participants not experiencing an event into a higher-risk category. Because of the low event rate in the cohort, reclassification mainly occurred in the group classified as at low risk (<5%) according to the PCE.

Conclusions and relevance: Information on coronary atherosclerosis from CCTA modestly improved risk prediction beyond traditional risk factors and CACS in identifying individuals at risk of coronary events and in need of primary prevention.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Björnson reported receipt of personal fees from Arrowhead Pharmaceuticals and Novartis and nonfinancial support from Ribocure Pharmaceuticals. Dr T. Andersson reported receipt of speakers’ honoraria from Bristol Myers Squibb. Dr Hagström reported receipt of grants (paid to institution) from Pfizer, Amgen, and Novo Nordisk; personal fees from Amgen, Novo Nordisk, Bayer, AstraZeneca, Amarin, Novartis, and Ultragenyx; and advisory board participation for Amarin. Dr James reported receipt of research support (paid to institution) from AstraZeneca, Jansen, Novo Nordisk, and Amgen; consulting fees from Medtronic, Edwards, AstraZeneca, and Lilly; payment for lectures from Amgen and Novo Nordisk; and advisory board participation for New Amsterdam and Celecor. Dr Katsoularis reported receipt of speakers’ honoraria from Pfizer and AstraZeneca. Dr Markstad reported receipt of grants from the Southern Sweden Healthcare Region and stock ownership in Nordea Bank, Bulten, VBG Group B, SynAct Pharma, Rivian Automotive A, and Merck. Dr Oldgren reported receipt of institutional research grants from Amgen, AstraZeneca, Bayer, Novo Nordisk, and Roche Diagnostics; advisory board fees (paid to institution) from Regeneron; and lecture fees (paid to institution) from Pfizer. Dr Persson reported being a board member of and having stock ownership in Sectra. Dr Spaak reported receipt of speaker honoraria from Bayer, AstraZeneca, Boehringer Ingelheim, and Novo Nordisk; stock ownership in Beat Vascular Health; and being principal investigator in clinical trials for Neko Health, Boehringer Ingelheim, and Novo Nordisk. Dr Sundström reported direct or indirect stock ownership in Sence Research, Symptoms Europe, MinForskning, and Anagram Kommunikation and providing services to companies and authorities in the health sector, including Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Lilly, Gilead, GSK, University of Gothenburg, Itrim, Ipsen, Janssen, Karolinska Institutet, LIF, Linköping University, Novo Nordisk, Parexel, Pfizer, Region Stockholm, Region Uppsala, Sanofi, Strama, Takeda, TLV, Uppsala University, Vifor Pharma, and WeMind. Dr Söderberg reported receipt of speakers’ honoraria and travel support from Johnson & Johnson and advisory board and/or scientific board participation for Johnson & Johnson and MSD. Dr Jernberg reported stock ownership in Levahealth. No other disclosures were reported.

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