Coronary revascularization vs. medical therapy following coronary-computed tomographic angiography in patients with low-, intermediate- and high-risk coronary artery disease: results from the CONFIRM long-term registry.
OBJECTIVE
To identify the effect of early revascularization on 5-year survival in patients with CAD diagnosed by coronary-computed tomographic angiography (CCTA).


RESULTS
We examined 5544 stable patients with suspected CAD undergoing CCTA who were followed a median of 5.5 years in a large international registry. Patients were categorized as having low-, intermediate-, or high-risk CAD based on CCTA findings. Two treatment groups were defined: early revascularization within 90 days of CCTA (n = 1171) and medical therapy (n = 4373). To account for the non-randomized referral to revascularization, we developed a propensity score by logistic regression. This score was incorporated into Cox proportional hazard models to calculate the effect of revascularization on all-cause mortality. Death occurred in 363 (6.6%) patients and was more frequent in medical therapy. In multivariable models, when compared with medical therapy, the mortality benefit of revascularization varied significantly over time and by CAD risk (P for interaction 0.04). In high-risk CAD, revascularization was significantly associated with lower mortality at 1 year (hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.11-0.47) and 5 years (HR 0.31, 95% CI 0.18-0.54). For intermediate-risk CAD, revascularization was associated with reduced mortality at 1 year (HR 0.45, 95% CI 0.22-0.93) but not 5 years (HR 0.63, 95% CI 0.33-1.20). For low-risk CAD, there was no survival benefit at either time point.


CONCLUSIONS
Early revascularization was associated with reduced 1-year mortality in intermediate- and high-risk CAD detected by CCTA, but this association only persisted for 5-year mortality in high-risk CAD.
Division of Cardiology, Albany Medical College, Albany, NY, USA.
Joshua
J
Schulman-Marcus
Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY, USA.
Fay Y
FY
Lin
Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
Heidi
H
Gransar
Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
Daniel
D
Berman
Tennessee Heart and Vascular Institute, Hendersonville, TN, USA.
Tracy
T
Callister
Capital Cardiology Associates, Albany, NY, USA.
Augustin
A
DeLago
Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany.
Martin
M
Hadamitzky
Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany.
Joerg
J
Hausleiter
King Saud Bin Abdul Aziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdul Aziz Cardiac Center, Ministry of National Guard, Health Affairs, Saudi Arabia.
Mouaz
M
Al-Mallah
Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA, USA.
Matthew
M
Budoff
University Hospital, Zurich, Switzerland.
Philipp
P
Kaufmann
Department of Medicine, University of Erlangen, Erlangen, Germany.
Stephan
S
Achenbach
William Beaumont Hospital, Royal Oaks, MI, USA.
Gilbert
G
Raff
Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy.
Kavitha
K
Chinnaiyan
Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy.
Filippo
F
Cademartiri
Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy.
Erica
E
Maffei
Department of Medicine, Walter Reed Medical Center, Washington, DC, USA.
Todd
T
Villines
Seoul National University Hospital, Seoul, South Korea.
Yong-Jin
YJ
Kim
Department of Medicine and Radiology, University of British Columbia, Vancouver, BC, Canada.
Jonathon
J
Leipsic
Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
Gudrun
G
Feuchtner
Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
Ronen
R
Rubinshtein
Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Gianluca
G
Pontone
Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
Daniele
D
Andreini
Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal.
Hugo
H
Marques
Division of Cardiology, Severance Cardiovascular Hospital, Seoul, South Korea.
Hyuk-Jae
HJ
Chang
Department of Medicine and Radiology, University of Ottawa, ON, Canada.
Benjamin J W
BJW
Chow
Baptist Cardiac and Vascular Institute, Miami, FL, USA.
Ricardo C
RC
Cury
Duke Clinical Research Institute, Durham, NC, USA.
Allison
A
Dunning
Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
Leslee
L
Shaw
Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY, USA.
James K
JK
Min
D000367:Age Factors; D000368:Aged; D000704:Analysis of Variance; D002316:Cardiotonic Agents / Q000008:administration & dosage*; D002423:Cause of Death; D000072226:Computed Tomography Angiography / Q000379:methods; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000401:mortality / Q000628:therapy*; D005260:Female; D006801:Humans; D038622:Internationality; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009204:Myocardial Revascularization / Q000379:methods*; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000379:methods / Q000401:mortality; D011379:Prognosis; D016016:Proportional Hazards Models; D012042:Registries; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D016019:Survival Analysis; D016896:Treatment Outcome
D002316:Cardiotonic Agents
CAD; coronary-computed tomographic angiography; revascularization