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Impact of Plaque Burden vs. Stenosis on Adverse Events
Quick Takes
- Calcified coronary plaque burden rather than stenosis severity is the main predictor of risk for future cardiovascular events.
- When stratified by coronary artery calcium score, the presence of obstructive CAD was not associated with a higher risk of adverse events.
Study Questions:
In patients with coronary artery disease (CAD), does the presence of an obstructive lesion provide prognostic value over calcified plaque burden, as measured by coronary artery calcium (CAC)?
Methods:
This study evaluated 23,759 symptomatic patients from a registry who underwent clinically indicated coronary computed tomography angiography (CTA) and evaluated the risk of adverse events (myocardial infarction, stroke, all-cause mortality) stratified by CAC severity (0, 1-99, 100-399, 400-1,000, and >1,000) and the number of arteries with obstructive (>50% stenosis) stenoses.
Results:
Mean age was 57.4 years and 44.6% were male. Adverse events occurred in 1,054 patients over a median follow-up of 4.3 years. Increased CAC scores and number of arteries with obstructive CAD were individually associated with increased risk of adverse events. For each CAC category adjusted for cardiovascular risk factors, the presence of obstructive CAD was not independently associated with adverse events over nonobstructive CAD.
Conclusions:
In symptomatic patients undergoing coronary CTA, higher CAC severity was independently associated with increased adverse events, while the presence of obstructive CAD was not associated with higher risk within each CAC score category. This suggests that patients with similar calcium scores have comparable risks of adverse events regardless of the presence or absence of obstructive CAD.
Perspective:
This observational study finds that the presence of obstructive CAD does not add prognostic value over CAC score in symptomatic patients referred for coronary CTA. These findings may not apply to patients with more significant symptoms or risk factors which could have resulted in direct referrals for invasive angiography rather than coronary CTA. While findings of obstructive CAD may have resulted in more invasive angiography procedures and resulting coronary revascularizations, the authors performed additional analyses excluding patients with revascularization within 90 days and observed similar findings. Patients with obstructive CAD had higher rates of comorbidities, worse lipid and blood pressure profiles, and higher rates of pretest aspirin and statin use than patients with nonobstructive CAD. While the study adjusted for many potential risk factors, there is a potential for unmeasured variables to impact these results. Nevertheless, these results suggest that CAC score severity can be used to risk stratify symptomatic patients referred for coronary CTA, and that the presence of obstructive CAD may not add significant clinical value to this risk assessment.
Clinical Topics: Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Nonstatins, Novel Agents, Statins, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging
Keywords: Angiography, Aspirin, Blood Pressure, Constriction, Pathologic, Coronary Artery Disease, Coronary Stenosis, Diagnostic Imaging, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Plaque, Atherosclerotic, Primary Prevention, Risk Assessment, Risk Factors, Stroke, Tomography, X-Ray Computed, Vascular Diseases
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