title: Prognostic value of coronary CTA vs. exercise treadmill testing: results from the Partners registry.
abstract: OBJECTIVE
  We sought to compare the complementary prognostic value of exercise treadmill testing (ETT) and coronary computed tomographic angiography (CTA) among patients referred for both exams.
  
  
  RESULTS
  We studied 582 patients without known coronary artery disease (CAD) who were clinically referred for ETT and CTA within 6 months. Patients were followed for cardiovascular (CV) death, non-fatal myocardial infarction (MI), or late revascularization (>90 days), stratified by Duke Treadmill Score (DTS) and CAD severity (≥50% stenosis). Mean age was 54 ± 13 years (63% male). In median follow-up of 40 months, there were 3 CV deaths, 7 non-fatal MIs, and 26 late revascularizations. ETT was inconclusive in 23%, positive in 31%, and negative in 46%. CTA demonstrated no CAD in 37%, non-obstructive CAD in 28%, and obstructive CAD in 35%. Among low-risk ETT patients (n = 326), there were 3 MI, 10 late revascularizations, and the frequent presence of non-obstructive (32%, n = 105) and obstructive CAD (27%, n = 88). When present, ETT features (i.e., angina, DTS, ischaemic electrocardiogram changes, and exercise capacity) individually failed to predict CV death/MI after adjustment for Morise score. Conversely, both obstructive CAD [HR 4.9 (1.0-23.3), P = 0.048] and CAD extent by segment involvement score >4 [HR 3.9 (1.0-15.2), P = 0.049] predicted increased risk for CV death or MI.
  
  
  CONCLUSIONS
  Patients with a low-risk ETT have an excellent prognosis at 40 months, despite the frequent presence of non-obstructive (32%) and obstructive (27%) CAD. In patients with an intermediate- to high-risk ETT (DTS <5), CTA can provide incremental risk stratification for future CV events.
authors.affiliation: Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Cheezum
authors.affiliation: Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Prem Srinivas
authors.initials: PS
authors.lastname: Subramaniyam
authors.affiliation: Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA Center for Clinical and Epidemiological Research, Division of Internal Medicine, University of São Paulo, São Paulo, Brazil.
authors.forename: Marcio S
authors.initials: MS
authors.lastname: Bittencourt
authors.affiliation: Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA Cardiology Service, Division of Medicine, Walter Reed National Military Medical Center and Uniformed Services University of Health Sciences, Bethesda, MD, USA.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Hulten
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Brian B
authors.initials: BB
authors.lastname: Ghoshhajra
authors.affiliation: Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA.
authors.forename: Nishant R
authors.initials: NR
authors.lastname: Shah
authors.affiliation: Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Forman
authors.affiliation: Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA.
authors.forename: Jon
authors.initials: J
authors.lastname: Hainer
authors.affiliation: Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Marcia
authors.initials: M
authors.lastname: Leavitt
authors.affiliation: Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Ram
authors.initials: R
authors.lastname: Padmanabhan
authors.affiliation: Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA.
authors.forename: Hicham
authors.initials: H
authors.lastname: Skali
authors.affiliation: Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA.
authors.forename: Sharmila
authors.initials: S
authors.lastname: Dorbala
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Udo
authors.initials: U
authors.lastname: Hoffmann
authors.affiliation: Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
authors.forename: Suhny
authors.initials: S
authors.lastname: Abbara
authors.affiliation: Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA.
authors.forename: Marcelo F
authors.initials: MF
authors.lastname: Di Carli
authors.affiliation: Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Henry
authors.initials: H
authors.lastname: Gewirtz
authors.affiliation: Non-Invasive Cardiovascular Imaging Program, Departments of Medicine and Radiology (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Shapiro Room 5096, Boston, MA 02115, USA rblankstein@partners.org.
authors.forename: Ron
authors.initials: R
authors.lastname: Blankstein
mesh_terms: D017023:Coronary Angiography; D003327:Coronary Disease / Q000000981:diagnostic imaging* / Q000401:mortality / Q000503:physiopathology*; D005080:Exercise Test; D005260:Female; D006801:Humans; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D008875:Middle Aged; D011379:Prognosis; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed
keywords: coronary artery disease; coronary computed tomographic angiography; exercise testing; major adverse cardiac events; prognosis