Coronary atherosclerosis scoring with semiquantitative CCTA risk scores for prediction of major adverse cardiac events: Propensity score-based analysis of diabetic and non-diabetic patients

Inge J Van Den Hoogen,Ronen Rubinshtein,Stephan Achenbach,Alexander R Van Rosendael,Hugo Marques,Benjamin J.W Chow,Jeroen J Bax,Gudrun Feuchtner,Fay Y Lin,Jeff M Smit,James K Min,Ricardo C Cury,Aukelien C Dimitriu-Leen,Yao Lu,Filippo Cademartiri,Pedro De Araújo Gonçalves,Matthew J Budoff,Augustin Delago,Martin Hadamitzky,Leslee J Shaw,Erica Maffei,Heidi Gransar,Tracy Q Callister,Gianluca Pontone,Daniele Andreini,Daniel S Berman,Jessica M Peña,Philipp A Kaufmann,Todd C Villines,Mouaz H Al‐Mallah ,Yong Jin Kim ,Hyuk Jae Chang ,Gilbert Raff ,Jonathon Leipsic ,Jöerg Hausleiter ,Arthur J Scholte ,Edward Jones ,Kavitha M Chinnaiyan

doi:10.1016/j.jcct.2019.11.015

Abstract

AimsWe aimed to compare semiquantitative coronary computed tomography angiography (CCTA) risk scores – which score presence, extent, composition, stenosis and/or location of coronary artery disease (CAD) – and their prognostic value between patients with and without diabetes mellitus (DM). Risk scores derived from general chest-pain populations are often challenging to apply in DM patients, because of numerous confounders. MethodsOut of a combined cohort from the Leiden University Medical Center and the CONFIRM registry with 5-year follow-up data, we performed a secondary analysis in diabetic patients with suspected CAD who were clinically referred for CCTA. A total of 732 DM patients was 1:1 propensity-matched with 732 non-DM patients by age, sex and cardiovascular risk factors. A subset of 7 semiquantitative CCTA risk scores was compared between groups: 1) any stenosis ≥50%, 2) any stenosis ≥70%, 3) stenosis-severity component of the coronary artery disease-reporting and data system (CAD-RADS), 4) segment involvement score (SIS), 5) segment stenosis score (SSS), 6) CT-adapted Leaman score (CT-LeSc), and 7) Leiden CCTA risk score. Cox-regression analysis was performed to assess the association between the scores and the primary endpoint of all-cause death and non-fatal myocardial infarction. Also, area under the receiver-operating characteristics curves were compared to evaluate discriminatory ability. ResultsA total of 1,464 DM and non-DM patients (mean age 58 ± 12 years, 40% women) underwent CCTA and 155 (11%) events were documented after median follow-up of 5.1 years. In DM patients, the 7 semiquantitative CCTA risk scores were significantly more prevalent or higher as compared to non-DM patients (p ≤ 0.022). All scores were independently associated with the primary endpoint in both patients with and without DM (p ≤ 0.020), with non-significant interaction between the scores and diabetes (interaction p ≥ 0.109). Discriminatory ability of the Leiden CCTA risk score in DM patients was significantly better than any stenosis ≥50% and ≥70% (p = 0.003 and p = 0.007, respectively), but comparable to the CAD-RADS, SIS, SSS and CT-LeSc that also focus on the extent of CAD (p ≥ 0.265). ConclusionCoronary atherosclerosis scoring with semiquantitative CCTA risk scores incorporating the total extent of CAD discriminate major adverse cardiac events well, and might be useful for risk stratification of patients with DM beyond the binary evaluation of obstructive stenosis alone.

Highlights

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in developed countries, and coronary atherosclerosis accounts for the most substantial proportion of CVD [1]
Prior papers that report a serial follow-up of coronary plaque progression have been mainly based on quantitative coronary angiography, intravascular ultrasound (IVUS) or optical coherence tomography (OCT) [6,7], all of which carry an inherent limitation of selection bias for high-risk patients owing to the invasiveness of the methods used
The baseline degree of coronary atherosclerosis is the sole important factor associated with the growth of coronary plaque, age was as important as any other traditional cardiovascular risk factors

Summary

Introduction

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in developed countries, and coronary atherosclerosis accounts for the most substantial proportion of CVD [1]. Because age and dyslipidemia are important risk factors for coronary artery disease (CAD), several guidelines recommend the consideration of using lipid-lowering agents by age groups [2,3] and mainly, focuses on middle-aged groups, i.e. 40~75 years old. Prior papers that report a serial follow-up of coronary plaque progression have been mainly based on quantitative coronary angiography, intravascular ultrasound (IVUS) or optical coherence tomography (OCT) [6,7], all of which carry an inherent limitation of selection bias for high-risk patients owing to the invasiveness of the methods used. Coronary CT angiography (CCTA) is an adequate noninvasive modality to analyze the progression of coronary plaque according to age in low-to-intermediate CAD risk population, as compared to invasive modalities such as IVUS [8]. The use of noninvasive imaging to analyze the progression of CAD is very useful because it sheds light to understanding the natural history of CAD in the general population

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