Reply
Martin Hadamitzky, MD*
We thank Dr. Rassi (1) for his interest in our study (2) and the opportunity to highlight some points that were possibly not sufficiently highlighted in the original publication. The prognostic value of coronary computed tomographic angiography (CTA) in our study was established based on the significant difference observed regarding the composite end point of cardiac death, myocardial infarction, and rehospitalization for unstable angina. The majority of cardiologists will agree that, although on a different degree, each of these is an important adverse event that should be prevented. A large number of trials have chosen this combination as a primary end point when comparing various drugs or treatment strategies. The results of our study are further strengthened by the observation of a significant difference in respect to all cause mortality (see Table 2 in our study [2]). This is a relevant finding considering our limited ability to precisely define the cause of death.
Many colleagues will agree that an ischemia driven revascularization procedure is also an important adverse event. Angina pectoris causes considerable morbidity and coronary revascularization is a well proven symptomatic therapy, it may even improve survival (3). The difference found in our study regarding this outcome can only reinforce the overall message about the prognostic value of CTA.
Regarding Dr. Rassi's last point, we agree that our study population does not completely match the asymptomatic Framingham population (3). Nevertheless, not taking into account current cardiac symptoms (as does the Framingham algorithm [4]) will rather underestimate the patient risk, and the difference in the definition of adverse events of interest mostly reflects the progress of diagnosis and treatment of coronary artery disease since the 1970s and 1980s. Even so, all observed adverse events of our study met the end point criteria of the original Framingham study (5). Therefore we believe it is adequate to use this well established score to demonstrate that the event rate after normal CTA is lower than predicted by conventional risk factors.
* Deutsches Herzzentrum München, Klinik für Erwachsenenkardiologie, Lazarettstrasse 36, Munich, Bavaria 80636, Germany (Email: mhy{at}dhm.mhn.de).
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REFERENCES
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- Rassi Jr A. Prognostic utility of coronary computed tomography angiography: are we looking at the correct outcomes and making appropriate comparisons? J Am Coll Cardiol Img 2009;2:914.[Free Full Text]
- Hadamitzky M, Freiβmuth B, Meyer T, et al. Prognostic value of coronary computed tomographic angiography for prediction of cardiac events in patients with suspected coronary artery disease J Am Coll Cardiol Img 2009;2:404-411.[Abstract/Free Full Text]
- Schömig A, Mehilli J, de Waha A, Seyfarth M, Pache J, Kastrati A. A meta-analysis of 17 randomized trials of a percutaneous coronary intervention-based strategy in patients with stable coronary artery disease J Am Coll Cardiol 2008;52:894-904.[Abstract/Free Full Text]
- Anderson KM, Wilson PW, Odell PM, Kannel WB. An updated coronary risk profile. A statement for health professionals. Circulation 1991;83:356-362.[Free Full Text]
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Related Article
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Prognostic Utility of Coronary Computed Tomography Angiography: Are We Looking at the Correct Outcomes and Making Appropriate Comparisons?
- Anis Rassi, Jr
J. Am. Coll. Cardiol. Img. 2009 2: 914.
[Full Text]
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