title: Differential incremental value of ultrasound carotid intima-media thickness, carotid plaque, and cardiac calcium to predict angiographic coronary artery disease across Framingham risk score strata in the APRES multicentre study.
abstract: OBJECTIVE
  According to recent data, more accurate selection of patients undergoing coronary angiography for suspected coronary artery disease (CAD) is needed. From the Active PREvention Study multicentre prospective study, we further analyse whether carotid intima-media thickness (cIMT), carotid plaques (cPL), and echocardiographic cardiac calcium score (eCS) have incremental discriminatory and reclassification predictive value for CAD over clinical risk score in subjects undergoing coronary angiography, specifically depending on their low, intermediate, or high class of clinical risk.
  
  
  RESULTS
  In eight centres, 445 subjects without history of prior CAD but with chest pain of recent onset and/or a positive/inconclusive stress test for ischaemia prospectively underwent clinically indicated elective coronary angiography after cardiac and carotid ultrasound assessments with measurements of cIMT, cPL, and eCS. The study population was divided into subjects at low (10%), intermediate (10-20%), and high (>20%) Framingham risk score (FRS). Ultrasound parameters were tested for their incremental value to predict CAD over FRS, in each pre-test risk category. No significant difference could be appreciated between the discrimination value of FRS and Diagnostic Imaging for Coronary Artery Disease score for the presence of CAD. eCS or cPL demonstrated significant incremental prediction over FRS, consistently in the three FRS categories (P < 0.01); this applied to both discrimination and reclassification, with the exception of high-risk subjects, in whom cPL was apparently not incremental over FRS, and eCS was only of borderline significance for better discrimination.
  
  
  CONCLUSIONS
  Ultrasound eCS and cPL assessments were significant predictors of angiographic CAD in patients without prior CAD but with signs or symptoms suspect for CAD, independently and incrementally to FRS, across all pre-test risk probability strata, although in high-risk subjects, only eCS maintained an incremental value. The use of cIMT was not significantly incrementally useful in any FRS risk category.
authors.affiliation: Department of Cardiology, Parma University Hospital, Via Gramsci, 14, Parma 43124, Italy ngaibazzi@gmail.com.
authors.forename: Nicola
authors.initials: N
authors.lastname: Gaibazzi
authors.affiliation: Hospital dell'Angelo, Mestre-Venice, Italy.
authors.forename: Fausto
authors.initials: F
authors.lastname: Rigo
authors.affiliation: Niguarda Ca' Granda Hospital and Milano-Bicocca University, Milan, Italy.
authors.forename: Rita
authors.initials: R
authors.lastname: Facchetti
authors.affiliation: University of Messina Hospital, Messina, Italy.
authors.forename: Scipione
authors.initials: S
authors.lastname: Carerj
authors.affiliation: Niguarda Ca' Granda Hospital and Milano-Bicocca University, Milan, Italy.
authors.forename: Cristina
authors.initials: C
authors.lastname: Giannattasio
authors.affiliation: Niguarda Ca' Granda Hospital and Milano-Bicocca University, Milan, Italy.
authors.forename: Antonella
authors.initials: A
authors.lastname: Moreo
authors.affiliation: S. Giovanni-Addolorata Hospital, Roma, Italy.
authors.forename: Gian Francesco
authors.initials: GF
authors.lastname: Mureddu
authors.affiliation: Internal Medicine, University of Brescia, Brescia, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Salvetti
authors.affiliation: Hospital dell'Angelo, Mestre-Venice, Italy.
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Grolla
authors.affiliation: Spedali Civili Hospital Brescia, Brescia, Italy.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Faden
authors.affiliation: Niguarda Ca' Granda Hospital and Milano-Bicocca University, Milan, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Cesana
authors.affiliation: Spedali Civili Hospital Brescia, Brescia, Italy.
authors.forename: Pompilio
authors.initials: P
authors.lastname: Faggiano
mesh_terms: D000368:Aged; D019540:Area Under Curve; D002114:Calcinosis / Q000000981:diagnostic imaging / Q000473:pathology; D059168:Carotid Intima-Media Thickness / Q000009:adverse effects*; D016893:Carotid Stenosis / Q000000981:diagnostic imaging* / Q000401:mortality / Q000473:pathology; D015331:Cohort Studies; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000401:mortality / Q000473:pathology; D004452:Echocardiography / Q000379:methods*; D005260:Female; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D058226:Plaque, Atherosclerotic / Q000000981:diagnostic imaging* / Q000401:mortality / Q000473:pathology; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D018570:Risk Assessment; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D018608:Ultrasonography, Doppler
keywords: carotid intima–media thickness; coronary angiography; coronary artery disease; risk factors; ultrasound cardiac calcium