Total plaque score (TPS) on coronary computed tomography angiography (CCTA) has been validated as a surrogate measure of coronary artery disease (CAD) burden and is prognostic. We propose a novel measure, percentage TPS adjusted to age (%TPS/age), that may reflect vascular age and potentially more rapidly progressive atherosclerosis and evaluate its potential prognostic value.
Methods:
%TPS/age was calculated for consecutive patients prospectively enrolled into our institutional CCTA registry and evaluated for primary composite outcome of cardiac death, nonfatal myocardial infarction, and late revascularization.
Results:
Of 1896 patients identified (mean age 57.7 ± 11.4 years, 50.1% male, median follow-up 18.6 months [interquartile range: 15.3, 32.4]), 552 (29%) had %TPS/age = 0 (no atherosclerosis), with 1 (0.2%) primary outcome observed (annual event rate [AER] = 0.1%). Two events (0.4%, AER = 0.3%) were observed in %TPS/age < 0.314 category, 22 (5.0%, AER = 2.2%) in %TPS/age 0.314 to 0.699 category, and 54 (12.0%, AER = 5.7%) in %TPS/age ≥ 0.700 category. After adjusting for clinical predictors and obstructive CAD, higher %TPS/age category was associated with hazard ratio 1.95 (1.31-2.88, P < .001) for primary outcome on multivariable analysis, Harrell-C-Statistic 0.87 (confidence interval 95%: 0.84-0.90), and net reclassification improvement of 0.71 (P < .001).
Conclusion:
%TPS/Age has incremental prognostic value to traditional risk factors and CCTA measures of CAD and improves evaluation of burden of coronary atherosclerosis and clinical risk.
BittencourtMSHultenEGhoshhajraB. Prognostic value of nonobstructive and obstructive coronary artery disease detected by coronary computed tomography angiography to identify cardiovascular events. Circ Cardiovasc Imaging. 2014;7(2):282–291.
2.
MinJKDunningALinFY. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol. 2011;58(8):849–860.
3.
LinFYShawLJDunningAM. Mortality risk in symptomatic patients with nonobstructive coronary artery disease: a prospective 2-center study of 2,583 patients undergoing 64-detector row coronary computed tomographic angiography. J Am Coll Cardiol. 2011;58(5):510–519.
4.
VirmaniRBurkeAPFarbAKolodgieFD. Pathology of the vulnerable plaque. J Am Coll Cardiol. 2006;47(8 suppl):C13–C18.
5.
BurgstahlerCReimannABeckT. Influence of a lipid-lowering therapy on calcified and noncalcified coronary plaques monitored by multislice detector computed tomography: results of the New Age II Pilot Study. Invest Radiol. 2007;42(3):189–195.
6.
KitagawaTYamamotoHHoriguchiJ. Effects of statin therapy on non-calcified coronary plaque assessed by 64-slice computed tomography. Int J Cardiol. 2011;150(2):146–150.
7.
MolletNRCademartiriFvan MieghemCA. High-resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography. Circulation. 2005;112(15):2318–2323.
8.
LehmanSJSchlettCLBambergF. Assessment of coronary plaque progression in coronary computed tomography angiography using a semiquantitative score. JACC Cardiovasc Imaging. 2009;2(11):1262–1270.
9.
ChowBJWellsGAChenL. Prognostic value of 64-slice cardiac computed tomography severity of coronary artery disease, coronary atherosclerosis, and left ventricular ejection fraction. J Am Coll Cardiol. 2010;55(10):1017–1028.
10.
MinJKShawLJDevereuxRB. Prognostic value of multidetector coronary computed tomographic angiography for prediction of all-cause mortality. J Am Coll Cardiol. 2007;50(12):1161–1170.
11.
NichollsSJHsuAWolskiK. Intravascular ultrasound-derived measures of coronary atherosclerotic plaque burden and clinical outcome. J Am Coll Cardiol. 2010;55(21):2399–2407.
12.
WatersDCravenTELesperanceJ. Prognostic significance of progression of coronary atherosclerosis. Circulation. 1993;87(4):1067–1075.
13.
RaggiPCallisterTQShawLJ. Progression of coronary artery calcium and risk of first myocardial infarction in patients receiving cholesterol-lowering therapy. Arterioscler Thromb Vasc Biol. 2004;24(7):1272–1277.
14.
InoueKMotoyamaSSaraiM. Serial coronary CT angiography-verified changes in plaque characteristics as an end point: evaluation of effect of statin intervention. JACC Cardiovasc Imaging. 2010;3(7):691–698.
15.
CallisterTQRaggiPCooilBLippolisNJRussoDJ. Effect of HMG-CoA reductase inhibitors on coronary artery disease as assessed by electron-beam computed tomography. N Engl J Med. 1998;339(27):1972–1978.
16.
SchmidMAchenbachSRopersD. Assessment of changes in non-calcified atherosclerotic plaque volume in the left main and left anterior descending coronary arteries over time by 64-slice computed tomography. Am J Cardiol. 2008;101(5):579–584.
17.
ZebILiDNasirK. Effect of statin treatment on coronary plaque progression - a serial coronary CT angiography study. Atherosclerosis. 2013;231(2):198–204.
18.
BudoffMJLaneKLBakhsheshiH. Rates of progression of coronary calcium by electron beam tomography. Am J Cardiol. 2000;86(1):8–11.
19.
MaherJEBielakLFRazJASheedyPF IISchwartzRSPeyserPA. Progression of coronary artery calcification: a pilot study. Mayo Clin Proc. 1999;74(4):347–355.
20.
RaggiPCooilBShawLJ. Progression of coronary calcium on serial electron beam tomographic scanning is greater in patients with future myocardial infarction. Am J Cardiol. 2003;92(7):827–829.
21.
AchenbachSRopersDPohleK. Influence of lipid-lowering therapy on the progression of coronary artery calcification: a prospective evaluation. Circulation. 2002;106(9):1077–1082.
KronmalRAMcClellandRLDetranoR. Risk factors for the progression of coronary artery calcification in asymptomatic subjects: results from the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2007;115(21):2722–2730.
24.
YoonHCEmerickAMHillJAGjertsonDWGoldinJG. Calcium begets calcium: progression of coronary artery calcification in asymptomatic subjects. Radiology. 2002;224(1):236–241.
25.
WongNDKawakuboMLaBreeLAzenSPXiangMDetranoR. Relation of coronary calcium progression and control of lipids according to National Cholesterol Education Program guidelines. Am J Cardiol. 2004;94(4):431–436.
26.
CassidyAEBielakLFZhouY. Progression of subclinical coronary atherosclerosis: does obesity make a difference?Circulation. 2005;111(15):1877–1882.
27.
HoffmannUDerflerKHaasMStadlerABradyTJKostnerK. Effects of combined low-density lipoprotein apheresis and aggressive statin therapy on coronary calcified plaque as measured by computed tomography. Am J Cardiol. 2003;91(4):461–464.
28.
ChowBJAbrahamAWellsGA. Diagnostic accuracy and impact of computed tomographic coronary angiography on utilization of invasive coronary angiography. Circ Cardiovasc Imaging. 2009;2(1):16–23.
29.
National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults Adult Treatment Panel III. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. Washington, DC: National Institutes of Health, 2009
30.
DiamondGAForresterJS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979;300(24):1350–1358.
31.
ChaitmanBRBourassaMGDavisK. Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation. 1981;64(2):360–367.
32.
GibbonsRJChatterjeeKDaleyJ. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). J Am Coll Cardiol. 1999;33(7):2092–2197.
33.
AbbaraSArbab-ZadehACallisterTQ. SCCT guidelines for performance of coronary computed tomographic angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr. 2009;3(3):190–204.
34.
ChunEJLeeWChoiYH. Effects of nitroglycerin on the diagnostic accuracy of electrocardiogram-gated coronary computed tomography angiography. J Comput Assist Tomogr. 2008;32(1):86–92.
35.
PencinaMJD’AgostinoRB. Overall C as a measure of discrimination in survival analysis: model specific population value and confidence interval estimation. Stat Med. 2004;23(13):2109–2123.
36.
EfronBTibshiraniR. Bootstrap methods for standard errors, confidence intervals, and other measures of statistical accuracy. Stat Sci. 1986;1(1):54–77.
37.
PencinaMJD’AgostinoRBSrD’AgostinoRBJrVasanRS. Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med. 2008;27(2):157–72; discussion 207-212.
38.
PencinaMJD’AgostinoRBSrSteyerbergEW. Extensions of net reclassification improvement calculations to measure usefulness of new biomarkers. Stat Med. 2011;30(1):11–21.
39.
AndreiniDPontoneGMushtaqS. A long-term prognostic value of coronary CT angiography in suspected coronary artery disease. JACC Cardiovasc Imaging. 2012;5(7):690–701.
40.
HadamitzkyMTaubertSDeseiveS. Prognostic value of coronary computed tomography angiography during 5 years of follow-up in patients with suspected coronary artery disease. Eur Heart J. 2013;34(42):3277–3285.
41.
LinFShawLJBermanDS. Multidetector computed tomography coronary artery plaque predictors of stress-induced myocardial ischemia by SPECT. Atherosclerosis. 2008;197(2):700–709.
42.
NakanishiRRanaJSRozanskiA. Relationship of dyspnea vs. typical angina to coronary artery disease severity, burden, composition and location on coronary CT angiography. Atherosclerosis. 2013;230(1):61–66.
43.
NakazatoRArsanjaniRAchenbachS. Age-related risk of major adverse cardiac event risk and coronary artery disease extent and severity by coronary CT angiography: results from 15 187 patients from the International Multisite CONFIRM Study. Eur Heart J Cardiovasc Imaging. 2014;15(5):586–594.
44.
ChoiTYLiDNasirK. Differences in coronary atherosclerotic plaque burden and composition according to increasing age on computed tomography angiography. Acad Radiol. 2013;20(2):202–208.
45.
SchmermundADenktasAERumbergerJA. Independent and incremental value of coronary artery calcium for predicting the extent of angiographic coronary artery disease: comparison with cardiac risk factors and radionuclide perfusion imaging. J Am Coll Cardiol. 1999;34(3):777–786.
46.
RifkinRDParisiAFFollandE. Coronary calcification in the diagnosis of coronary artery disease. Am J Cardiol. 1979;44(1):141–147.
47.
PriesterTCLitwinSE. Measuring progression of coronary atherosclerosis with computed tomography: searching for clarity among shades of gray. Journal of cardiovascular computed tomography. 2009;3(suppl 2):S81–S90.
48.
GreenlandPBonowROBrundageBH. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) developed in collaboration with the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol. 2007;49(3):378–402.
49.
NaghaviMLibbyPFalkE. From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part I. Circulation. 2003;108(147):1664–1672.
50.
GreenlandPAlpertJSBellerGA. 2010ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2010;122(25):e584–e636.
51.
RoySKCespedesALiDChoiTYBudoffMJ. Chronic kidney disease is associated with increased coronary artery atherosclerosis as revealed by multidetector computed tomographic angiography. Tex Heart Inst J. 2012;39(6):811–816.
