title: Stable angina pectoris: head-to-head comparison of prognostic value of cardiac CT and exercise testing.
abstract: OBJECTIVE
  To determine and compare the prognostic value of cardiac computed tomographic (CT) angiography, coronary calcium scoring, and exercise electrocardiography (ECG) in patients with chest pain who are suspected of having coronary artery disease (CAD).
  
  
  METHODS
  This study complied with the Declaration of Helsinki, and the local ethics committee approved the study. Patients (n = 471) without known CAD underwent exercise ECG and dual-source CT at a rapid assessment outpatient chest pain clinic. Coronary calcification and the presence of 50% or greater coronary stenosis (in one or more vessels) were assessed with CT. Exercise ECG results were classified as normal, ischemic, or nondiagnostic. The primary outcome was a major adverse cardiac event (MACE), defined as cardiac death, nonfatal myocardial infarction, or unstable angina requiring hospitalization and revascularization beyond 6 months. Univariable and multivariable Cox regression analysis was used to determine the prognostic values, while clinical impact was assessed with the net reclassification improvement metric.
  
  
  RESULTS
  Follow-up was completed for 424 (90%) patients; the mean duration of follow-up was 2.6 years. A total of 44 MACEs occurred in 30 patients. Four of the MACEs were cardiac deaths and six were nonfatal myocardial infarctions. The presence of coronary calcification (hazard ratio [HR], 8.22 [95% confidence interval {CI}: 1.96, 34.51]), obstructive CAD (HR, 6.22 [95% CI: 2.77, 13.99]), and nondiagnostic stress test results (HR, 3.00 [95% CI: 1.26, 7.14]) were univariable predictors of MACEs. In the multivariable model, CT angiography findings (HR, 5.0 [95% CI: 1.7, 14.5]) and nondiagnostic exercise ECG results (HR, 2.9 [95% CI: 1.2, 7.0]) remained independent predictors of MACEs. CT angiography findings showed incremental value beyond clinical predictors and stress testing (global χ(2), 37.7 vs 13.7; P < .001), whereas coronary calcium scores did not have further incremental value (global χ(2), 38.2 vs 37.7; P = .40).
  
  
  CONCLUSIONS
  CT angiography findings are a strong predictor of future adverse events, showing incremental value over clinical predictors, stress testing, and coronary calcium scores.
  
  
  BACKGROUND
  http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11110744/-/DC1.
authors.affiliation: Department of Cardiology, Erasmus University Medical Centre, 's-Gravendijkwal 230, PO Box 2040, 3000 CA Rotterdam, The Netherlands. a.dedic@erasmusmc.nl
authors.forename: Admir
authors.initials: A
authors.lastname: Dedic
authors.forename: Tessa S S
authors.initials: TS
authors.lastname: Genders
authors.forename: Bart S
authors.initials: BS
authors.lastname: Ferket
authors.forename: Tjebbe W
authors.initials: TW
authors.lastname: Galema
authors.forename: Nico R A
authors.initials: NR
authors.lastname: Mollet
authors.forename: Adriaan
authors.initials: A
authors.lastname: Moelker
authors.forename: M G Myriam
authors.initials: MG
authors.lastname: Hunink
authors.forename: Pim J
authors.initials: PJ
authors.lastname: de Feyter
authors.forename: Koen
authors.initials: K
authors.lastname: Nieman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000787:Angina Pectoris / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D002114:Calcinosis / Q000000981:diagnostic imaging / Q000503:physiopathology; D016009:Chi-Square Distribution; D003287:Contrast Media; D017023:Coronary Angiography / Q000379:methods*; D004562:Electrocardiography; D005080:Exercise Test; D005260:Female; D005466:Fluorocarbons; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000503:physiopathology; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D014057:Tomography, X-Ray Computed / Q000379:methods*
chemical_list: D003287:Contrast Media; D005466:Fluorocarbons; C042852:perflutren