title: A long-term prognostic value of CT angiography and exercise ECG in patients with suspected CAD.
abstract: OBJECTIVE
  The aim of the study was to perform a comparison of the prognostic performance of computed tomography coronary angiography (CTA) and exercise electrocardiography (ex-ECG) in patients with suspected coronary artery disease (CAD).
  
  
  BACKGROUND
  CAD is a major cause of mortality and morbidity, and its management consumes a large proportion of the health care budget. Therefore, identification of patients at high risk of adverse events is crucial. Despite its limited accuracy, ex-ECG is the most commonly used noninvasive test in CAD evaluation. CTA was recently introduced as alternative test.
  
  
  METHODS
  We enrolled 681 patients (age 61.3 ± 10.4 years, 461 men) with atypical or typical angina and no history of CAD. All patients underwent ex-ECG and CTA and were followed for 44 ±12 months. The endpoints were all cardiac events, defined as nonfatal myocardial infarction, cardiac death, and revascularization, and hard cardiac events, defined as all cardiac events excluding revascularization.
  
  
  RESULTS
  ex-ECG and CTA were rated as positive in 419 (61%) and 274 (40%) of 681 patients, respectively. In univariate analysis, both ex-ECG and CTA were predictors of all cardiac events (hazard ratio [HR]: 2.09, 95% confidence interval [CI]: 1.5 to 2.8; p < 0.0001 and HR: 21.1, 95% CI: 14.6 to 30.5; p < 0.0001, respectively) and hard cardiac events (HR: 1.9, 95% CI: 1.1 to 3.2; p = 0.02 and HR: 6.8, 95% CI: 3.9 to 11.0; p < 0.0001, respectively), whereas in a multivariate analysis, CAD with ≥50% stenoses detected by CTA was the only independent predictor of hard cardiac events. Stratifying our population by ex-ECG and CTA findings, Kaplan-Meier curves showed that ex-ECG provides only a further risk stratification in the subset of patients with positive findings on CTA and a low to intermediate likelihood of CAD. Moreover, positive findings on CTA identify a shorter event-free period, regardless the ex-ECG findings for both all cardiac events and hard cardiac events, respectively.
  
  
  CONCLUSIONS
  CTA may have a higher prognostic value compared with ex-ECG in patients with suspected CAD, mainly in those with a low to intermediate pre-test likelihood of CAD.
authors.affiliation: Centro Cardiologico Monzino, IRCCS, Milan, Italy. gianluca.pontone@ccfm.it
authors.forename: Gianluca
authors.initials: G
authors.lastname: Pontone
authors.forename: Daniele
authors.initials: D
authors.lastname: Andreini
authors.forename: Antonio L
authors.initials: AL
authors.lastname: Bartorelli
authors.forename: Erika
authors.initials: E
authors.lastname: Bertella
authors.forename: Sarah
authors.initials: S
authors.lastname: Cortinovis
authors.forename: Saima
authors.initials: S
authors.lastname: Mushtaq
authors.forename: Claudia
authors.initials: C
authors.lastname: Foti
authors.forename: Andrea
authors.initials: A
authors.lastname: Annoni
authors.forename: Alberto
authors.initials: A
authors.lastname: Formenti
authors.forename: Andrea
authors.initials: A
authors.lastname: Baggiano
authors.forename: Edoardo
authors.initials: E
authors.lastname: Conte
authors.forename: Francesca
authors.initials: F
authors.lastname: Bovis
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Veglia
authors.forename: Giovanni
authors.initials: G
authors.lastname: Ballerini
authors.forename: Cesare
authors.initials: C
authors.lastname: Fiorentini
authors.forename: Piergiuseppe
authors.initials: P
authors.lastname: Agostoni
authors.forename: Mauro
authors.initials: M
authors.lastname: Pepi
mesh_terms: D000368:Aged; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D018450:Disease Progression; D004562:Electrocardiography; D005080:Exercise Test; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality / Q000628:therapy; D009204:Myocardial Revascularization; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors