title: All-cause mortality benefit of coronary revascularization vs. medical therapy in patients without known coronary artery disease undergoing coronary computed tomographic angiography: results from CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry).
abstract: OBJECTIVE
  To date, the therapeutic benefit of revascularization vs. medical therapy for stable individuals undergoing invasive coronary angiography (ICA) based upon coronary computed tomographic angiography (CCTA) findings has not been examined.
  
  
  RESULTS
  We examined 15 223 patients without known coronary artery disease (CAD) undergoing CCTA from eight sites and six countries who were followed for median 2.1 years (interquartile range 1.4-3.3 years) for an endpoint of all-cause mortality. Obstructive CAD by CCTA was defined as a ≥50% luminal diameter stenosis in a major coronary artery. Patients were categorized as having high-risk CAD vs. non-high-risk CAD, with the former including patients with at least obstructive two-vessel CAD with proximal left anterior descending artery involvement, three-vessel CAD, and left main CAD. Death occurred in 185 (1.2%) patients. Patients were categorized into two treatment groups: revascularization (n = 1103; 2.2% mortality) and medical therapy (n = 14 120, 1.1% mortality). To account for non-randomized referral to revascularization, we created a propensity score developed by logistic regression to identify variables that influenced the decision to refer to revascularization. Within this model (C index 0.92, χ2 = 1248, P < 0.0001), obstructive CAD was the most influential factor for referral, followed by an interaction of obstructive CAD with pre-test likelihood of CAD (P = 0.0344). Within CCTA CAD groups, rates of revascularization increased from 3.8% for non-high-risk CAD to 51.2% high-risk CAD. In multivariable models, when compared with medical therapy, revascularization was associated with a survival advantage for patients with high-risk CAD [hazards ratio (HR) 0.38, 95% confidence interval 0.18-0.83], with no difference in survival for patients with non-high-risk CAD (HR 3.24, 95% CI 0.76-13.89) (P-value for interaction = 0.03).
  
  
  CONCLUSIONS
  In an intermediate-term follow-up, coronary revascularization is associated with a survival benefit in patients with high-risk CAD by CCTA, with no apparent benefit of revascularization in patients with lesser forms of CAD.
authors.affiliation: Department of Medicine, Imaging, and Biomedical Sciences, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, 8700 Beverly Blvd., S. Taper Building 1258, Los Angeles, CA 90048, USA. james.min@cshs.org
authors.forename: James K
authors.initials: JK
authors.lastname: Min
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Berman
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authors.lastname: Dunning
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authors.forename: Mouaz
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authors.forename: Filippo
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authors.lastname: Callister
authors.forename: Hyuk-Jae
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authors.lastname: Chang
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authors.lastname: Cheng
authors.forename: Kavitha
authors.initials: K
authors.lastname: Chinnaiyan
authors.forename: Benjamin J W
authors.initials: BJ
authors.lastname: Chow
authors.forename: Ricardo
authors.initials: R
authors.lastname: Cury
authors.forename: Augustin
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authors.lastname: Delago
authors.forename: Gudrun
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authors.lastname: Feuchtner
authors.forename: Martin
authors.initials: M
authors.lastname: Hadamitzky
authors.forename: Joerg
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authors.lastname: Hausleiter
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authors.initials: P
authors.lastname: Kaufmann
authors.forename: Ronald P
authors.initials: RP
authors.lastname: Karlsberg
authors.forename: Yong-Jin
authors.initials: YJ
authors.lastname: Kim
authors.forename: Jonathon
authors.initials: J
authors.lastname: Leipsic
authors.forename: Fay Y
authors.initials: FY
authors.lastname: Lin
authors.forename: Erica
authors.initials: E
authors.lastname: Maffei
authors.forename: Fabian
authors.initials: F
authors.lastname: Plank
authors.forename: Gilbert
authors.initials: G
authors.lastname: Raff
authors.forename: Todd
authors.initials: T
authors.lastname: Villines
authors.forename: Troy M
authors.initials: TM
authors.lastname: Labounty
authors.forename: Leslee J
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mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002316:Cardiotonic Agents / Q000627:therapeutic use*; D017023:Coronary Angiography / Q000379:methods / Q000401:mortality; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000401:mortality*; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data; D057216:Propensity Score; D011446:Prospective Studies; D014057:Tomography, X-Ray Computed / Q000379:methods / Q000401:mortality; D055815:Young Adult
chemical_list: D002316:Cardiotonic Agents