title: Incremental prognostic utility of coronary CT angiography for asymptomatic patients based upon extent and severity of coronary artery calcium: results from the COronary CT Angiography EvaluatioN For Clinical Outcomes InteRnational Multicenter (CONFIRM) study.
abstract: OBJECTIVE
  Prior evidence observed no predictive utility of coronary CT angiography (CCTA) over the coronary artery calcium score (CACS) and the Framingham risk score (FRS), among asymptomatic individuals. Whether the prognostic value of CCTA differs for asymptomatic patients, when stratified by CACS severity, remains unknown.
  
  
  RESULTS
  From a 12-centre, 6-country observational registry, 3217 asymptomatic individuals without known coronary artery disease (CAD) underwent CACS and CCTA. Individuals were categorized by CACS as: 0-10, 11-100, 101-400, 401-1000, >1000. For CCTA analysis, the number of obstructive vessels-as defined by the per-patient presence of a ≥50% luminal stenosis-was used to grade the extent and severity of CAD. The incremental prognostic value of CCTA over and above FRS was measured by the likelihood ratio (LR) χ(2), C-statistic, and continuous net reclassification improvement (NRI) for prediction, discrimination, and reclassification of all-cause mortality and non-fatal myocardial infarction. During a median follow-up of 24 months (25th-75th percentile, 17-30 months), there were 58 composite end-points. The incremental value of CCTA over FRS was demonstrated in individuals with CACS >100 (LRχ(2), 25.34; increment in C-statistic, 0.24; NRI, 0.62, all P < 0.001), but not among those with CACS ≤100 (all P > 0.05). For subgroups with CACS >100, the utility of CCTA for predicting the study end-point was evident among individuals whose CACS ranged from 101 to 400; the observed predictive benefit attenuated with increasing CACS.
  
  
  CONCLUSIONS
  Coronary CT angiography provides incremental prognostic utility for prediction of mortality and non-fatal myocardial infarction for asymptomatic individuals with moderately high CACS, but not for lower or higher CACS.
authors.affiliation: Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno Seodaemungu, Seoul, South Korea Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA.
authors.forename: Iksung
authors.initials: I
authors.lastname: Cho
authors.affiliation: Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno Seodaemungu, Seoul, South Korea hjchang@yuhs.ac.
authors.forename: Hyuk-Jae
authors.initials: HJ
authors.lastname: Chang
authors.affiliation: Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA.
authors.forename: Bríain
authors.initials: B
authors.lastname: Ó Hartaigh
authors.affiliation: Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno Seodaemungu, Seoul, South Korea.
authors.forename: Sanghoon
authors.initials: S
authors.lastname: Shin
authors.affiliation: Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, 250 Seongsanno Seodaemungu, Seoul, South Korea.
authors.forename: Ji Min
authors.initials: JM
authors.lastname: Sung
authors.affiliation: Department of Medicine, NewYork-Presbyterian Hospital and Weill Cornell Medical College, New York, NY, USA.
authors.forename: Fay Y
authors.initials: FY
authors.lastname: Lin
authors.affiliation: Department of Medicine, University of Erlangen, Erlangen, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Achenbach
authors.affiliation: Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Ran
authors.initials: R
authors.lastname: Heo
authors.affiliation: Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Berman
authors.affiliation: Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA, USA.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Budoff
authors.affiliation: Tennessee Heart and Vascular Institute, Hendersonville, TN, USA.
authors.forename: Tracy Q
authors.initials: TQ
authors.lastname: Callister
authors.affiliation: Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI, USA.
authors.forename: Mouaz H
authors.initials: MH
authors.lastname: Al-Mallah
authors.affiliation: Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Filippo
authors.initials: F
authors.lastname: Cademartiri
authors.affiliation: William Beaumont Hospital, Royal Oaks, MI, USA.
authors.forename: Kavitha
authors.initials: K
authors.lastname: Chinnaiyan
authors.affiliation: Department of Medicine and Radiology, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Benjamin J W
authors.initials: BJ
authors.lastname: Chow
authors.affiliation: Duke Clinical Research Institute, Durham, NC, USA.
authors.forename: Allison M
authors.initials: AM
authors.lastname: Dunning
authors.affiliation: Capitol Cardiology Associates, Albany, NY, USA.
authors.forename: Augustin
authors.initials: A
authors.lastname: DeLago
authors.affiliation: Department of Medicine, Walter Reed Medical Center, Washington, DC, USA.
authors.forename: Todd C
authors.initials: TC
authors.lastname: Villines
authors.affiliation: Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Hadamitzky
authors.affiliation: Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany.
authors.forename: Joerg
authors.initials: J
authors.lastname: Hausleiter
authors.affiliation: Department of Medicine and Radiology, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Jonathon
authors.initials: J
authors.lastname: Leipsic
authors.affiliation: Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Leslee J
authors.initials: LJ
authors.lastname: Shaw
authors.affiliation: University Hospital, Zurich, Switzerland.
authors.forename: Philipp A
authors.initials: PA
authors.lastname: Kaufmann
authors.affiliation: Baptist Cardiac and Vascular Institute, Miami, FL, USA.
authors.forename: Ricardo C
authors.initials: RC
authors.lastname: Cury
authors.affiliation: Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
authors.forename: Gudrun
authors.initials: G
authors.lastname: Feuchtner
authors.affiliation: Seoul National University Hospital, Seoul, South Korea.
authors.forename: Yong-Jin
authors.initials: YJ
authors.lastname: Kim
authors.affiliation: Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Erica
authors.initials: E
authors.lastname: Maffei
authors.affiliation: William Beaumont Hospital, Royal Oaks, MI, USA.
authors.forename: Gilbert
authors.initials: G
authors.lastname: Raff
authors.affiliation: Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Pontone
authors.affiliation: Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
authors.forename: Daniele
authors.initials: D
authors.lastname: Andreini
authors.affiliation: Department of Radiology, NewYork-Presbyterian Hospital and the Weill Cornell Medical College, New York, NY, USA.
authors.forename: James K
authors.initials: JK
authors.lastname: Min
mesh_terms: D017023:Coronary Angiography / Q000379:methods / Q000401:mortality; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality; D011379:Prognosis; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed / Q000379:methods / Q000401:mortality; D061205:Vascular Calcification / Q000000981:diagnostic imaging* / Q000401:mortality
keywords: Asymptomatic; Coronary artery calcium scoring; Coronary computed tomographic angiography; Framingham risk score; Prognostic