Prognostic Value of Coronary CTA in Stable Chest Pain: CAD-RADS, CAC, and Cardiovascular Events in PROMISE

doi:10.1016/j.jcmg.2019.09.012

JACC: Cardiovascular Imaging

Volume 13, Issue 7, July 2020, Pages 1534-1545

https://doi.org/10.1016/j.jcmg.2019.09.012 Get rights and content

Under an Elsevier user license

open archive

Abstract

Objectives

The purpose of this study was to compare Coronary Artery Disease Reporting and Data System (CAD-RADS) to traditional stenosis categories and the coronary artery calcium score (CACS) for predicting cardiovascular events in patients with stable chest pain and suspected coronary artery disease (CAD).

Background

The 2016 CAD-RADS has been established to standardize the reporting of CAD on coronary CT angiography (CTA).

Methods

PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial participants’ CTAs were assessed by a central CT core laboratory for CACS, traditional stenosis-based categories, and modified CAD-RADS grade including high-risk coronary plaque (HRP) features. Traditional stenosis categories and CAD-RADS grade were compared for the prediction of the composite endpoint of death, myocardial infarction, or hospitalization for unstable angina over a median follow-up of 25 months. Incremental prognostic value over traditional risk factors and CACS was assessed.

Results

In 3,840 eligible patients (mean age: 60.4 ± 8.2 years; 49% men), 3.0% (115) experienced events. CAD-RADS (concordance statistic [C-statistic] 0.747) had significantly higher discriminatory value than traditional stenosis-based assessments (C-statistic 0.698 to 0.717; all p for comparison ≤0.001). With no plaque (CAD-RADS 0) as the baseline, the hazard ratio (HR) for an event increased from 2.43 (95% confidence interval [CI]: 1.16 to 5.08) for CAD-RADS 1 to 21.84 (95% CI: 8.63 to 55.26) for CAD-RADS 4b and 5. In stepwise nested models, CAD-RADS added incremental prognostic value beyond ASCVD risk score and CACS (C-statistic 0.776 vs. 0.682; p < 0.001), and added incremental value persisted in all CACS strata.

Conclusions

These data from a large representative contemporary cohort of patients undergoing coronary CTA for stable chest pain support the prognostic value of CAD-RADS as a standard reporting system for coronary CTA.

Central Illustration

Key Words

coronary CT angiography

coronary artery disease

coronary stenosis

coronary artery calcium

CAD-RADS

prognosis

high-risk plaque

Abbreviations and Acronyms

ASCVD

atherosclerotic cardiovascular disease

CACS

coronary artery calcium score

CAD

coronary artery disease

CAD-RADS

Coronary Artery Disease Reporting and Data System

CTA

computed tomography angiography

HRP

high-risk plaque

left main coronary artery

MACE

major adverse cardiovascular event

unstable angina

Cited by (0)

: The parent PROMISE trial was supported by National Heart, Lung, and Blood Institute grants R01HL098237, R01HL098236, R01HL98305, and R01HL098235. Dr. Bittner was supported by NIH/NHLBI 5K24HL113128. Dr. Budoff has received grants from NIH during the conduct of the study and grants from General Electric outside the submitted work. Dr. Ferencik was supported by American Heart Association Grant 13FTF16450001; and has received grants from American Heart Association outside the submitted work. Dr. Douglas has received grants from HeartFlow outside the submitted work. Dr. Hoffmann was supported by K24HL113128; and has received grants from NIH-NHLBI National Heart, Lung, and Blood Institute, during the conduct of the study; grants from Duke University/Abbott US; grants from HeartFlow, Inc. and Kowa Company, Ltd.; grants and nonfinancial support from MedImmne, LLC.; and personal fees and nonfinancial support from Abbott US, outside the submitted work. Dr. Lu was supported by the American Heart Association Precision Medicine Institute 18UNPG34030172 and the Harvard University Center for- AIDS Research 5P30AI060354-14; and has received research support to his institution from the American Heart Association, Nvidia, Kowa, and Medimmune, outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

: The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors' institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Cardiovascular Imaging author instructions page.