Author + information
- Received January 19, 2017
- Revision received August 24, 2017
- Accepted August 24, 2017
- Published online January 1, 2018.
- Joe X. Xie, MDa,
- Ricardo C. Cury, MDb,
- Jonathon Leipsic, MDc,
- Matthew T. Crim, MD, MSc, MAa,
- Daniel S. Berman, MDd,
- Heidi Gransar, MSd,
- Matthew J. Budoff, MDe,
- Stephan Achenbach, MDf,
- Bríain Ó Hartaigh, PhDg,
- Tracy Q. Callister, MDh,
- Hugo Marques, MDi,
- Ronen Rubinshtein, MDj,
- Mouaz H. Al-Mallah, MDk,
- Daniele Andreini, MD, PhDl,
- Gianluca Pontone, MD, PhDl,
- Filippo Cademartiri, MD, PhDm,
- Erica Maffei, MDm,
- Kavitha Chinnaiyan, MDn,
- Gilbert Raff, MDn,
- Martin Hadamitzky, MDo,
- Joerg Hausleiter, MDp,
- Gudrun Feuchtner, MDq,
- Allison Dunning, MSr,
- Augustin DeLago, MDs,
- Yong-Jin Kim, MDt,
- Philipp A. Kaufmann, MDu,
- Todd C. Villines, MDv,
- Benjamin J.W. Chow, MDw,
- Niree Hindoyan, BSg,
- Millie Gomez, MDg,
- Fay Y. Lin, MDg,
- Erica Jones, MDg,
- James K. Min, MDg and
- Leslee J. Shaw, PhDa,∗ ()
- aDivision of Cardiology, Emory University School of Medicine, Atlanta, Georgia
- bDivision of Cardiology, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, Florida
- cDivision of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
- dDivision of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
- eDivision of Cardiology, Harbor UCLA Medical Center, Los Angeles, California
- fDivision of Cardiology, University of Erlangen, Erlangen, Germany
- gDivision of Cardiology, Weill Cornell Medical College and the NewYork-Presbyterian Hospital, New York, New York
- hDivision of Cardiology, Tennessee Heart and Vascular Institute, Hendersonville, Tennessee
- iDivision of Cardiology, Hospital da Luz, Lisbon, Portugal
- jDivision of Cardiology, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- kDivision of Cardiology, Henry Ford Hospital, Detroit, Michigan
- lDivision of Cardiology, University of Milan, Centro Cardiologico Monzino, IRCCS Milan, Italy
- mDivision of Cardiology, Department of Radiology/Centre de Recherche, Montreal Heart Institute/Universitè de Montreal, Montreal, Quebec, Canada
- nDivision of Cardiology, William Beaumont Hospital, Royal Oaks, Michigan
- oDivision of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany
- pDivision of Cardiology, Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany
- qDivision of Cardiology, Medical University of Innsbruck, Innsbruck, Austria
- rDivision of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
- sDivision of Cardiology, Capitol Cardiology Associates, Albany, New York
- tDivision of Cardiology, Seoul National University Hospital, Seoul, South Korea
- uDivision of Cardiology, University Hospital, Zurich, Switzerland
- vDivision of Cardiology, Walter Reed Medical Center, Washington, DC
- wDivision of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- ↵∗Address for correspondence:
Dr. Leslee J. Shaw, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road North East, Room 529, Atlanta, Georgia 30324.
Objectives This study sought to assess clinical outcomes associated with the novel Coronary Artery Disease–Reporting and Data System (CAD-RADS) scores used to standardize coronary computed tomography angiography (CTA) reporting and their potential utility in guiding post-coronary CTA care.
Background Clinical decision support is a major focus of health care policies aimed at improving guideline-directed care. Recently, CAD-RADS was developed to standardize coronary CTA reporting and includes clinical recommendations to facilitate patient management after coronary CTA.
Methods In the multinational CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry, 5,039 patients without known coronary artery disease (CAD) underwent coronary CTA and were stratified by CAD-RADS scores, which rank CAD stenosis severity as 0 (0%), 1 (1% to 24%), 2 (25% to 49%), 3 (50% to 69%), 4A (70% to 99% in 1 to 2 vessels), 4B (70% to 99% in 3 vessels or ≥50% left main), or 5 (100%). Kaplan-Meier and multivariable Cox models were used to estimate all-cause mortality or myocardial infarction (MI). Receiver-operating characteristic (ROC) curves were used to compare CAD-RADS to the Duke CAD Index and traditional CAD classification. Referrals to invasive coronary angiography (ICA) after coronary CTA were also assessed.
Results Cumulative 5-year event-free survival ranged from 95.2% to 69.3% for CAD-RADS 0 to 5 (p < 0.0001). Higher scores were associated with elevations in event risk (hazard ratio: 2.46 to 6.09; p < 0.0001). The ROC curve for prediction of death or MI was 0.7052 for CAD-RADS, which was noninferior to the Duke Index (0.7073; p = 0.893) and traditional CAD classification (0.7095; p = 0.783). ICA rates were 13% for CAD-RADS 0 to 2, 66% for CAD-RADS 3, and 84% for CAD-RADS ≥4A. For CAD-RADS 3, 58% of all catheterizations occurred within the first 30 days of follow-up. In a patient subset with available medication data, 57% of CAD-RADS 3 patients who received 30-day ICA were either asymptomatic or not receiving antianginal therapy at baseline, whereas only 32% had angina and were receiving medical therapy.
Conclusions CAD-RADS effectively identified patients at risk for adverse events. Frequent ICA use was observed among patients without severe CAD, many of whom were asymptomatic or not taking antianginal drugs. Incorporating CAD-RADS into coronary CTA reports may provide a novel opportunity to promote evidence-based care post-coronary CTA.
Funding for this research was supported by NIH-NHLBI (5T32HL007745-20). Dr. Al-Mallah has received Speakers Bureau fees from GE Healthcare and Phillips. Dr. Andreini has received personal fees from GE Healthcare. Dr. Berman has been a consultant with Molecular Dynamics; has been employed and receives royalties from Cedars-Sinai Medical Center; and has received a grant with Bayer Pharmaceutical. Dr. Budoff has received grants from NIH and GE. Dr. Chow has received research support from GE Healthcare and CV Diagnostic; and educational support from TeraRecon Inc. Dr. Hausleiter has received personal fees from Abbott Vascular and Edwards Lifesciences. Dr. Leipsic has received personal fees from HeartFlow Inc., Circle CVI, GE Healthcare, Samsung, and Phillips. Dr. Min has received funding from NIH/NHLBI under grant RO1 HL115150; and has reported affiliations with MDDX, HeartFlow Inc., and Arineta. Dr. Pontone has received grants and speaker fees from GE Healthcare; speakers fees from Medtronic and Bracco; and grants from HeartFlow Inc. Dr. Raff has received a research grant from HeartFlow Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. William Weintraub, MD, served as the Guest Editor for this paper.
- Received January 19, 2017.
- Revision received August 24, 2017.
- Accepted August 24, 2017.
- 2018 American College of Cardiology Foundation