title: Prognostic value of cardiac computed tomography angiography: a systematic review and meta-analysis.
abstract: OBJECTIVE
  The purpose of this study was to systematically review and perform a meta-analysis of the ability of cardiac computed tomography angiography (CCTA) to predict future cardiovascular events and death.
  
  
  BACKGROUND
  The diagnostic accuracy of CCTA is well reported. The prognostic value of CCTA has been described in several studies, but many were underpowered. Pooling outcomes increases the power to predict rare events.
  
  
  METHODS
  We searched multiple databases for longitudinal studies of CCTA with at least 3 months follow-up of symptomatic patients with suspected coronary artery disease (CAD) reporting major adverse cardiovascular events (MACE), consisting of death, myocardial infarction (MI), and revascularization. Annualized event rates were pooled using a bivariate mixed-effects binomial regression model to calculate summary likelihood ratios and receiver-operating characteristic curves.
  
  
  RESULTS
  Eighteen studies evaluated 9,592 patients with a median follow-up of 20 months. The pooled annualized event rate for obstructive (any vessel with >50% luminal stenosis) versus normal CCTA was 8.8% versus 0.17% per year for MACE (p < 0.05) and 3.2% versus 0.15% for death or MI (p < 0.05). The pooled negative likelihood ratio for MACE after normal CCTA findings was 0.008 (95% confidence interval [CI]: 0.0004 to 0.17, p < 0.001), the positive likelihood ratio was 1.70 (95% CI: 1.42 to 2.02, p < 0.001), sensitivity was 0.99 (95% CI: 0.93 to 1.00, p < 0.001), and specificity was 0.41 (95% CI: 0.31 to 0.52, p < 0.001). Stratifying by no CAD, nonobstructive CAD (worst stenosis <50%), or obstructive CAD, there were incrementally increasing adverse events.
  
  
  CONCLUSIONS
  Adverse cardiovascular events among patients with normal findings on CCTA are rare. There are incrementally increasing future MACE with increasing CAD by CCTA.
authors.affiliation: Cadiology Service, Walter Reed Army Medical Center, Washington, DC, USA. edward.hulten@us.army.mil
authors.forename: Edward A
authors.initials: EA
authors.lastname: Hulten
authors.forename: Salvatore
authors.initials: S
authors.lastname: Carbonaro
authors.forename: Sara P
authors.initials: SP
authors.lastname: Petrillo
authors.forename: Joshua D
authors.initials: JD
authors.lastname: Mitchell
authors.forename: Todd C
authors.initials: TC
authors.lastname: Villines
mesh_terms: D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000401:mortality; D023921:Coronary Stenosis / Q000000981:diagnostic imaging*; D006801:Humans; D017202:Myocardial Ischemia / Q000401:mortality; D009204:Myocardial Revascularization; D011379:Prognosis; D012372:ROC Curve; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed