title: Value of CACS compared with ETT and myocardial perfusion imaging for predicting long-term cardiac outcome in asymptomatic and symptomatic patients at low risk for coronary disease: clinical implications in a multimodality imaging world.
abstract: OBJECTIVE
  This prospective, observational study in 988 asymptomatic or symptomatic low-risk patients without prior coronary artery disease was conducted to define the relative value of coronary artery calcium score (CACS), exercise treadmill testing (ETT), and stress myocardial perfusion single-photon emission computed tomography (SPECT) variables in predicting long-term risk stratification.
  
  
  BACKGROUND
  CACS, ETT, and stress myocardial perfusion SPECT results predict patients' outcome. There are currently no data comparing their relative value in long-term risk stratification.
  
  
  METHODS
  Patients were stratified by Framingham risk score (FRS), with a median follow-up of 6.9 years. Cardiac events were defined as a composite of cardiac death, nonfatal myocardial infarction, and the need for coronary revascularization. Most patients (87%) were considered appropriate candidates for functional testing as defined by current appropriate use criteria.
  
  
  RESULTS
  The long-term cardiac event rate was 11.2% (1.6% per year). Multivariate risk predictors in all patients and in the appropriate use cohort were abnormal SPECT (hazard ratio [HR]: 1.83 and 1.99), ETT ischemia (HR: 1.70 and 1.76), decreasing exercise capacity (HR: 1.11 and 1.17), decreasing Duke treadmill score (HR: 1.07 for both), and CACS severity (HR: 1.29 for both), respectively. Throughout the 10-year follow-up, CACS improved risk prediction, with event rates ranging from 0.6% per year (CACS ≤10) to 3.7% per year (CACS >400) (p < 0.0001). CACS also improved risk prediction in all patients, in the appropriate use cohort and among those with low-risk ETT and SPECT results (all, p < 0.001). Area under the receiver-operating characteristic curve was increased when CACS variables (from 0.63 to 0.70; p = 0.01) but not ETT variables (from 0.63 to 0.65) were added to FRS. Moreover, net reclassification improvement was significantly increased when CACS was added to FRS + functional variables in all patients and in the appropriate use cohort (both, p < 0.0001).
  
  
  CONCLUSIONS
  CACS significantly improved long-term risk stratification beyond FRS, ETT, and SPECT results across the spectrum of clinical risk and importantly even among those who are currently considered appropriate candidates for functional testing or have low-risk functional test results. Our findings support CACS as a first-line test over ETT or SPECT for accurately assessing long-term risk in such patients.
authors: Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
authors: Su Min
authors: SM
authors: Chang
authors: Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
authors: Faisal
authors: F
authors: Nabi
authors: Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas.
authors: Jiaqiong
authors: J
authors: Xu
authors: Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
authors: Craig M
authors: CM
authors: Pratt
authors: Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
authors: Angela C
authors: AC
authors: Mahmarian
authors: Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
authors: Maria E
authors: ME
authors: Frias
authors: Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas. Electronic address: jmahmarian@HoustonMethodist.org.
authors: John J
authors: JJ
authors: Mahmarian
mesh_terms: D000328:Adult; D000368:Aged; D002114:Calcinosis / Q000175:diagnosis* / Q000453:epidemiology; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000453:epidemiology; D003331:Coronary Vessels / Q000000981:diagnostic imaging*; D005080:Exercise Test; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D018570:Risk Assessment / Q000379:methods*; D013781:Texas / Q000453:epidemiology; D013997:Time Factors; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods*
keywords: asymptomatic patients; coronary artery calcium score; exercise treadmill test; risk stratification