High-Sensitivity Troponin T Concentrations in Acute Chest Pain Patients Evaluated With Cardiac Computed Tomography

OBJECTIVES: For evaluation of patients with chest pain and suspected acute coronary syndrome (ACS), consensus guidelines recommend use of a cardiac troponin cut point that corresponds to the 99th percentile of a healthy population. Most conventional troponin methods lack sufficient precision at this low level.

METHODS: In a cross-sectional study, 377 patients (mean age 53.7 years, 64.2% male) with chest pain and low to intermediate likelihood for ACS were enrolled in the emergency department. Blood was tested with a precommercial high-sensitivity troponin T assay (hsTnT) and compared with a conventional cardiac troponin T method. Patients underwent a 64-slice coronary computed tomography coronary angiogram at the time of phlebotomy, on average 4 hours from initial presentation.

RESULTS: Among patients with acute chest pain, 37 (9.8%) had an ACS. Using the 99th percentile cut point for a healthy population (13 pg/mL), hsTnT had 62% sensitivity, 89% specificity, 38% positive predictive value, and 96% negative predictive value for ACS. Compared with the cardiac troponin T method, hsTnT detected 27% more ACS cases (P=.001), and an hsTnT above the 99th percentile strongly predicted ACS (odds ratio 9.0, 95% confidence interval 3.9 to 20.9, P<0.001). Independent of ACS diagnosis, computed tomography angiography demonstrated that concentrations of hsTnT were determined by numerous factors, including the presence and severity of coronary artery disease, left ventricular mass, left ventricular ejection fraction, and regional left ventricular dysfunction.

CONCLUSIONS: Among low- to intermediate-risk patients with chest pain, hsTnT provides good sensitivity and specificity for ACS. Elevation of hsTnT identifies patients with myocardial injury and significant structural heart disease, irrespective of the diagnosis of ACS.

PMID: 20194879

Determinants of Coronary Calcium Conversion Among Patients With a Normal Coronary Calcium Scan: What Is the “Warranty Period” for Remaining Normal?

OBJECTIVES: This study identified the incidence and predictors of conversion of a normal to abnormal coronary artery calcium (CAC) scan during serial CAC scanning over 5 years. Although a normal CAC scan signifies absence of significant atherosclerosis and is used to identify individuals at low clinical risk, the “warranty period” of a normal CAC scan relative to its ability to predict sustained absence of coronary atherosclerosis remains unknown.

METHODS: We assessed frequency of and time to progression, as well as proportional increase of CAC in 422 individuals with normal CAC scan (CAC = 0) undergoing annual CAC scanning for 5 years. Results were compared with those of a referent cohort of 621 individuals with baseline CAC scan (CAC >0).

RESULTS: A total of 106 (25.1%) patients with CAC = 0 developed CAC during follow-up at a mean time to conversion of 4.1 +/- 0.9 years. Incidence of conversion to CAC >0 was nonlinear and was highest in the fifth year. In multivariable analysis, progression to CAC >0 was associated with age, diabetes, and smoking (p < 0.01 for all). Among the 621 individuals with baseline CAC >0, only the presence of CAC itself, rather than CAD risk factors, was predictive of CAC progression. Among propensity score-matched individuals with CAC >0 versus CAC = 0, baseline CAC >0 emerged as the strongest predictor of CAC progression (hazard ratio [HR]: 12.50, 95% confidence interval [CI]: 9.31 to 16.77), followed by diabetes (HR: 2.07, 95% CI: 1.47 to 2.90) and smoking (HR: 1.29, 95% CI: 1.02 to 1.63, p < 0.05 for all).

CONCLUSIONS: Among individuals with CAC = 0, conversion to CAC >0 is nonlinear and occurs at low frequency before 4 years. No clinical factor seems to mandate earlier repeat CAC scanning.

PMID: 20223365

Do Additional Echocardiographic Variables Increase the Accuracy of E/e’ for Predicting Left Ventricular Filling Pressure in Normal Ejection Fraction? An Echocardiographic and Invasive Hemodynamic Study

OBJECTIVIES: There are few data on adding left atrial volume index (LAVi) or pulmonary artery systolic pressure (PAP) to the ratio of early mitral inflow to mitral annular velocity (E/e’) for the estimation of left ventricular (LV) filling pressure in patients with preserved LV ejection fractions (LVEFs) (>50%).

METHODS: Patients underwent echocardiography within 20 minutes of cardiac catheterization. Echocardiographic variables were compared with invasively measured LV preatrial contraction pressure (pre-A).

RESULTS: Of the 122 patients studied (mean age, 55 +/- 9 years; mean LVEF, 61 +/- 6%), 67 (55%) were women, 108 (88%) had hypertension, and 79 (65%) had significant coronary artery disease at catheterization. E/e’ was significantly correlated with pre-A (R = 0.63, P < .0001) compared with LAVi (R = 0.49, P < .001) and PAP (R = 0.48, P < .001). E/e’ > 13 had sensitivity of 70% and specificity of 93% (area under the curve [AUC], 0.82; P < .0001), LAVi > 31 mL/m2 had sensitivity of 78% and specificity of 76% (AUC, 0.80, P < .001), and PAP > 28 mm Hg had sensitivity of 80% and specificity of 64% for pre-A > 15 mm Hg (AUC, 0.77, P < .001). Adding LAVi >31 mL/m2 for E/e’ = 8 to 13 significantly increased the accuracy of E/e’ > 13 alone (sensitivity, 87%; specificity, 88%; AUC, 0.89; P = .01 for comparison). However, adding PAP > 28 mm Hg for E/e’ = 8 to 13 did not significantly increase the accuracy of E/e’ > 13 alone (AUC, 0.82; sensitivity, 82%; specificity, 72%; P = NS for comparison).

CONCLUSIONS: In patients with preserved LVEFs, adding LAVi > 31 mL/m2 to E/e’ (when E/e’ was in the gray zone, but not when E/e’ was >13) significantly increased the accuracy of E/e’ alone for the estimation of LV filling pressure. These data support the notion of using several, rather than any single, Doppler echocardiographic parameter for the accurate assessment of LV diastolic function.

PMID: 20152696

Patent Foramen Ovale: Echocardiographic Detection and Clinical Relevance in Stroke

This article reviews the main clinical aspects of patent foramen ovale (PFO), such as its prevalence in the population, the diagnostic techniques to detect its presence, its role as a risk factor for ischemic stroke of otherwise unexplained origin, and its controversial association with migraine. Some cofactors possibly involved in the association between PFO and stroke are discussed, along with the various therapeutic options to prevent recurrent cerebral ischemic events in stroke patients with a PFO.

PMID: 20152695

Mitral Cerclage Annuloplasty, A Novel Transcatheter Treatment for Secondary Mitral Valve Regurgitation: Initial Results in Swine

OBJECTIVES: We developed and tested a novel transcatheter circumferential annuloplasty technique to reduce mitral regurgitation in porcine ischemic cardiomyopathy. Catheter-based annuloplasty for secondary mitral regurgitation exploits the proximity of the coronary sinus to the mitral annulus, but is limited by anatomic variants and coronary artery entrapment.

METHODS: The procedure, “cerclage annuloplasty,” is guided by magnetic resonance imaging (MRI) roadmaps fused with live X-ray. A coronary sinus guidewire traverses a short segment of the basal septal myocardium to re-enter the right heart where it is exchanged for a suture. Tension is applied interactively during imaging and secured with a locking device.

RESULTS: We found 2 feasible suture pathways from the great cardiac vein across the interventricular septum to create cerclage. Right ventricular septal re-entry required shorter fluoroscopy times than right atrial re-entry, which entailed a longer intramyocardial traversal but did not cross the tricuspid valve. Graded tension progressively reduced septal-lateral annular diameter, but not end-systolic elastance or regional myocardial function. A simple arch-like device protected entrapped coronary arteries from compression even during supratherapeutic tension. Cerclage reduced mitral regurgitation fraction (from 22.8 +/- 12.7% to 7.2 +/- 4.4%, p = 0.04) by slice tracking velocity-encoded MRI. Flexible cerclage reduced annular size but preserved annular motion. Cerclage also displaced the posterior annulus toward the papillary muscles. Cerclage introduced reciprocal constraint to the left ventricular outflow tract and mitral annulus that enhanced leaflet coaptation. A sample of human coronary venograms and computed tomography angiograms suggested that most have suitable venous anatomy for cerclage.

CONCLUSIONS: Transcatheter mitral cerclage annuloplasty acutely reduces mitral regurgitation in porcine ischemic cardiomyopathy. Entrapped coronary arteries can be protected. MRI provided insight into the mechanism of cerclage action.

PMID: 19660696

Combined Dyssynchrony and Scar Imaging With Cardiac Magnetic Resonance Imaging Predicts Clinical Response and Long-Term Prognosis Following Cardiac Resynchronization Therapy

OBJECTIVES: Cardiac resynchronization therapy (CRT) is advocated in advanced heart failure; however, patient selection remains challenging. We examined the utility of multi-sequential cardiac magnetic resonance imaging (CMR) in predicting outcome after CRT.

METHODS: We performed multi-sequential CMR on 40 subjects with cardiomyopathy and advanced heart failure, despite optimized medical therapy. All patients had been recommended for CRT according to accepted clinical guidelines. Patients were defined by CMR as likely responders if they had significant mechanical dyssynchrony (≥65 ms delay between septal and posterolateral wall contraction on cine imaging), and no transmural scarring of the anteroseptal or posterolateral wall on delayed contrast-enhanced imaging. Clinical composite score was recorded at baseline and 6 months post-CRT.

RESULTS: Long-term follow-up (transplant-free survival) was 497 ± 55 days post-CRT. A clinical response was achieved in 19/26 (73%) of the CMR-predicted responders and 2/12 (17%) of the CMR-predicted non-responders (P < 0.01, χ²). The sensitivity of CMR for prediction of clinical response to CRT was 90%, with a specificity of 59%. Transplant-free survival post-CRT was achieved in 88% of the CMR-predicted responders and 58% of the CMR-predicted non-responders (P < 0.05, Kaplan–Meier survival analysis).

CONCLUSIONS: Multi-sequential CMR identifies patients with severe cardiomyopathy who will respond to CRT with a favourable long-term prognosis.

PMID: 20190262

Low Diagnostic Yield of Elective Coronary Angiography

BACKGROUND: Guidelines for triaging patients for cardiac catheterization recommend a risk assessment and noninvasive testing. We determined patterns of noninvasive testing and the diagnostic yield of catheterization among patients with suspected coronary artery disease in a contemporary national sample.

METHODS: From January 2004 through April 2008, at 663 hospitals in the American College of Cardiology National Cardiovascular Data Registry, we identified patients without known coronary artery disease who were undergoing elective catheterization. The patients’ demographic characteristics, risk factors, and symptoms and the results of noninvasive testing were correlated with the presence of obstructive coronary artery disease, which was defined as stenosis of 50% or more of the diameter of the left main coronary artery or stenosis of 70% or more of the diameter of a major epicardial vessel.

RESULTS: A total of 398,978 patients were included in the study. The median age was 61 years; 52.7% of the patients were men, 26.0% had diabetes, and 69.6% had hypertension. Noninvasive testing was performed in 83.9% of the patients. At catheterization, 149,739 patients (37.6%) had obstructive coronary artery disease. No coronary artery disease (defined as <20% stenosis in all vessels) was reported in 39.2% of the patients. Independent predictors of obstructive coronary artery disease included male sex (odds ratio, 2.70; 95% confidence interval [CI], 2.64 to 2.76), older age (odds ratio per 5-year increment, 1.29; 95% CI, 1.28 to 1.30), presence of insulin-dependent diabetes (odds ratio, 2.14; 95% CI, 2.07 to 2.21), and presence of dyslipidemia (odds ratio, 1.62; 95% CI, 1.57 to 1.67). Patients with a positive result on a noninvasive test were moderately more likely to have obstructive coronary artery disease than those who did not undergo any testing (41.0% vs. 35.0%; P<0.001; adjusted odds ratio, 1.28; 95% CI, 1.19 to 1.37).

CONCLUSIONS: In this study, slightly more than one third of patients without known disease who underwent elective cardiac catheterization had obstructive coronary artery disease. Better strategies for risk stratification are needed to inform decisions and to increase the diagnostic yield of cardiac catheterization in routine clinical practice.

PMID: 20220183

Evaluation of Contraindications and Efficacy of Oral Beta Blockade Before Computed Tomographic Coronary Angiography

OBJECTIVES: Multidetector computed tomographic coronary angiography (CTA) image quality is inversely related to the heart rate (HR). As a result beta-blocking medication is routinely administered before investigation. In the present study, the use, contraindications, and efficacy of prescan beta blockade with regard to HR reduction and CTA image quality were assessed.

METHODS: In 537 patients referred for CTA, the baseline HR and blood pressure were measured on arrival, and contraindications for beta blockade were noted. Unless contraindicated, a single dose of metoprolol was administered orally 1 hour before data acquisition in patients with a HR of >65 beats/min according to a predefined medication protocol. After 1 hour, the HR was remeasured.

RESULTS: A total of 283 patients (53%) had a HR of >65 beats/min. In this group, beta blockade was contraindicated in 46 patients (16%). Metoprolol was administered to the remaining 237 patients. However, 26 patients (11%) received suboptimal (lower dose than prescribed by protocol) beta blockade because of contraindications. Of the 211 patients receiving optimal beta blockade, 57 (27%) did not achieve the target HR. Of the patients with contraindications to beta blockade, 43 (60%) did not achieve the target HR. Compared to patients with optimal HR control, those receiving no or suboptimal beta blockade because of contraindications had significantly fewer examinations of good image quality (40% vs 74%, p <0.001), and significantly more examinations of poor image quality (20% vs 6%, p <0.001).

CONCLUSIONS: In conclusion, most patients require HR reduction before CTA. Contraindications to beta blockade are present in a substantial proportion of patients. This results in suboptimal HR control and image quality, indicating the need for alternative approaches for HR reduction.

PMID: 20211317

Transcatheter Aortic Valve Implantation for the Treatment of Severe Symptomatic Aortic Stenosis in Patients at Very High or Prohibitive Surgical Risk: Acute and Late Outcomes of the Multicenter Canadian Experience

OBJECTIVES: The aim of this study was: 1) to evaluate the acute and late outcomes of a transcatheter aortic valve implantation (TAVI) program including both the transfemoral (TF) and transapical (TA) approaches; and 2) to determine the results of TAVI in patients deemed inoperable because of either porcelain aorta or frailty. Very few data exist on the results of a comprehensive TAVI program including both TA and TF approaches for the treatment of severe aortic stenosis in patients at very high or prohibitive surgical risk.

METHODS: Consecutive patients who underwent TAVI with the Edwards valve (Edwards Lifesciences, Inc., Irvine, California) between January 2005 and June 2009 in 6 Canadian centers were included.

RESULTS: A total of 345 procedures (TF: 168, TA: 177) were performed in 339 patients. The predicted surgical mortality (Society of Thoracic Surgeons risk score) was 9.8 ± 6.4%. The procedural success rate was 93.3%, and 30-day mortality was 10.4% (TF: 9.5%, TA: 11.3%). After a median follow-up of 8 months (25th to 75th interquartile range: 3 to 14 months) the mortality rate was 22.1%. The predictors of cumulative late mortality were peri-procedural sepsis (hazard ratio [HR]: 3.49, 95% confidence interval [CI]: 1.48 to 8.28) or need for hemodynamic support (HR: 2.58, 95% CI: 1.11 to 6), pulmonary hypertension (PH) (HR: 1.88, 95% CI: 1.17 to 3), chronic kidney disease (CKD) (HR: 2.30, 95% CI: 1.38 to 3.84), and chronic obstructive pulmonary disease (COPD) (HR: 1.75, 95% CI: 1.09 to 2.83). Patients with either porcelain aorta (18%) or frailty (25%) exhibited acute outcomes similar to the rest of the study population, and porcelain aorta patients tended to have a better survival rate at 1-year follow-up.

CONCLUSIONS: A TAVI program including both TF and TA approaches was associated with comparable mortality as predicted by surgical risk calculators for the treatment of patients at very high or prohibitive surgical risk, including porcelain aorta and frail patients. Baseline (PH, COPD, CKD) and peri-procedural (hemodynamic support, sepsis) factors but not the approach determined worse outcomes.

PMID: 20096533

Right Ventricular Involvement in Acute Left Ventricular Myocardial Infarction: Prognostic Implications of MRI Findings

OBJECTIVE. The purpose of this study was to investigate the prevalence and prognostic importance of the cardiac MRI finding of right ventricular involvement in patients with acute ST-segment elevation myocardial infarction (MI).

METHODS. Fifty patients (41 men, nine women; mean age, 58 ± 11 years) with first-ST-segment elevation MI underwent 1.5-T cardiac MRI immediately after successful percutaneous coronary intervention. The cardiac MRI protocol included steady-state free precession cine sequences for functional assessment of the left, right, and both ventricles and inversion recovery FLASH delayed enhancement sequences after contrast administration for the quantification of myocardial damage. The prevalence of right ventricular involvement detected with ECG and echocardiography was compared with the prevalence detected with cardiac MRI, which was the reference standard. Patients underwent follow-up for 32 ± 8 months.

RESULTS. Right ventricular involvement was diagnosed with cardiac MRI in 27 patients (54%): 14 of 30 patients (47%) with inferior ST-segment elevation MI and 13 of 20 patients (65%) with anterior ST-segment elevation MI. ECG and echocardiographic findings showed only moderate agreement with cardiac MRI findings in the detection of right ventricular involvement in inferior acute MI (kappa = 0.38). Patients with right ventricular involvement in anterior ST-segment elevation MI had larger infarcts (delayed enhancement, 25.9% ± 14.5% vs 11.4% ± 10.1%; p = 0.030), lower left ventricular ejection fraction (34.3% ± 8.2% vs 45.2% ± 9.5%; p < 0.015), and lower right ventricular ejection fraction (39.8% ± 6.6% vs 54.9% ± 8.8%; p < 0.001) than those without right ventricular involvement. In a multivariate logistic regression model, right ventricular involvement was a strong independent predictor (odds ratio, 15.8; 95% CI, 4–63%) of major cardiac adverse events.

CONCLUSION. Right ventricular involvement in ST-segment elevation MI is detected more frequently with cardiac MRI than with ECG and echocardiography and is an independent prognostic indicator.

PMID: 20173133

High Resolution Myocardial Magnetic Resonance Stress Perfusion Imaging at 3T Using a 1M Contrast Agent

PMID: 19760241

Usefulness of Echocardiographic Dyssynchrony in Patients With Borderline QRS Duration to Assist With Selection for Cardiac Resynchronization Therapy

OBJECTIVES: To test the hypothesis that echocardiographic dyssynchrony may assist in the selection of patients with borderline QRS duration for cardiac resynchronization therapy (CRT). Although echocardiographic dyssynchrony is currently not recommended to select patients with QRS duration widening for CRT, its utility in patients with borderline QRS widening is unclear.

METHODS: Of 221 consecutive heart failure patients with an ejection fraction (EF) 35% referred for CRT, 86 had a borderline QRS duration of 100 to 130 ms (115 ± 8 ms) and 135 patients had wide QRS >130 ms (168 ± 26 ms). Dyssynchrony was assessed using interventricular mechanical delay, tissue Doppler imaging longitudinal velocity opposing wall delay, and speckle tracking radial strain for septal to posterior wall delay. Response to CRT was defined as 15% increase in EF, and reverse remodeling as 10% decrease in end-systolic volume.

RESULTS: There were 201 patients with baseline quantitative echocardiographic data available, and 187 with follow-up data available 8 ± 5 months after CRT. A smaller proportion of borderline QRS duration patients (53%) were EF responders compared with 75% with widened QRS (p < 0.05). Interventricular mechanical delay 40 ms and opposing wall delay 65 ms were predictive of EF response in the wide QRS duration group, but not the borderline QRS duration group. Speckle tracking radial dyssynchrony 130 ms, however, was predictive of EF response in both wide QRS interval patients (88% sensitivity, 74% specificity) and borderline QRS interval patients (79% sensitivity, 82% specificity) and associated reverse remodeling with reduction in end-systolic volume (p < 0.0005).

CONCLUSIONS: Radial dyssynchrony by speckle tracking strain was associated with EF and reverse remodeling response to CRT in patients with borderline QRS duration and has the potential to assist with patient selection.

PMID: 20159638

Assessment of Myocardial Viability at Dobutamine Echocardiography by Deformation Analysis Using Tissue Velocity and Speckle-Tracking

OBJECTIVES: Comparison of myocardial tissue-velocity imaging (TVI) and speckle-tracking echocardiography (STE) for prediction of viability at dobutamine echocardiography (DbE). Use of TVI-based strain imaging during DbE may facilitate the prediction of myocardial viability but has technical limitations. STE overcomes these but requires evaluation for prediction of viability.

METHODS: We studied 55 patients with ischemic heart disease and left ventricular systolic dysfunction (left ventricular ejection fraction <0.45) who were undergoing DbE for assessment of myocardial viability and who subsequently underwent myocardial revascularization. TVI was used to measure longitudinal end-systolic strain (longS) and peak systolic strain rate (SR) at rest and at low-dose dobutamine (LDD). Longitudinal, radial, and circumferential strain and strain rate were measured with STE. Segmental functional recovery was defined by improved wall-motion score on side-by-side comparison of echocardiographic images before and 9 months after revascularization and areas under the receiver operator characteristic curves were used to compare methods.

RESULTS: Of the 375 segments with abnormal resting function, 154 (41%) showed functional recovery. Only circumferential resting and low-dose STE strain and low-dose longitudinal strain and SR predicted functional recovery independent of wall-motion analysis. Among different strain parameters, only TVI-based longitudinal end-systolic strain and peak systolic SR at LDD had incremental value over wall-motion analysis (areas under the receiver operator characteristic curves of 0.79, 0.79, and 0.74, respectively). STE measurements of strain and SR identified viability only in the anterior circulation, whereas TVI strain and SR accurately identified viability in both anterior and posterior circulations.

CONCLUSIONS: Combination of TVI or STE methods with DbE can predict viability, with TVI strain and SR at LDD being the most accurate. TVI measures can predict viability in both anterior and posterior circulations, but STE measurements predict viability only in the anterior circulation.

PMID: 20159637

Coronary Microcirculatory Vasodilator Function in Relation to Risk Factors Among Patients Without Obstructive Coronary Disease and Low to Intermediate Framingham score

OBJECTIVES: The study aim was to evaluate the relation between the Framingham risk score (FRS) and the presence of coronary risk factors to coronary microcirculatory vasodilator function in patients with early coronary atherosclerosis.

METHODS: We evaluated 1063 patients (age: 50 +/- 12 years, 676 (64%) females) without significant narrowing (<30%) on coronary angiography who underwent invasive assessment of coronary endothelial function. Coronary blood flow (CBF) in response to the endothelium-dependent vasodilator acetylcholine was evaluated as well as the microvascular (endothelium-independent) coronary flow reserve (CFR) in response to intracoronary adenosine. Coronary blood flow and CFR were analysed in relation to the FRS and the presence of traditional and novel risk factors.

RESULTS: The estimated 10 years risk in this group was 5.4 +/- 5.2%. Higher FRS was associated with lower CBF in men (P = 0.008), and was a univariate predictor of lower CFR (P = 0.012) in all patients. Multivariable analysis identified a higher FRS (P < 0.001), female sex (P < 0.001) and a positive family history of coronary disease (P = 0.043) as independent predictors of reduced CFR.

CONCLUSIONS: In patients without obstructive coronary disease, a higher FRS was an independent predictor of reduced CFR. The current study provides insight into the relation between cardiac risk profile and coronary microcirculatory function, and suggests that impaired microcirculatory vasodilator function may be present even in patients with a low to intermediate Framingham score.

PMID: 19897496

Prognostic Value of 64-Slice Cardiac Computed Tomography: Severity of Coronary Artery Disease, Coronary Atherosclerosis, and Left Ventricular Ejection Fraction

OBJECTIVES: We sought to determine the prognostic and incremental value of coronary artery disease (CAD) severity, coronary atherosclerosis, and left ventricular ejection fraction (LVEF) measured with cardiac computed tomography angiography (CTA). CTA is an emerging tool used for the detection of obstructive CAD. However, there are limited data supporting the prognostic value of 64-slice CTA and its ability to predict all-cause mortality and major adverse cardiac events such as cardiac death and nonfatal myocardial infarction.

METHODS: Consecutive patients (without history of revascularization, heart transplantation, and congenital heart disease) were prospectively enrolled. Each CTA was evaluated for CAD severity, total plaque score, and LVEF. Patients were followed, and all events were confirmed with death certificates or hospital or physician records and reviewed by a clinical events committee.

RESULTS: Between February 2006 and February 2008, 2,076 consecutive patients were prospectively enrolled and followed for a mean of 16 ± 8 months. At follow-up, a total of 31 (1.5%) patients had cardiac death or nonfatal myocardial infarction and 47 (2.3%) had all-cause mortality or nonfatal myocardial infarction. Multivariate analysis showed that CAD severity (hazard ratio [HR]: 3.02; 95% confidence interval [CI]: 1.89 to 4.83) was a predictor of major adverse cardiac events and that LVEF (HR: 1.47; 95% CI: 1.17 to 1.86) had incremental value over CAD severity. Total plaque score had incremental value over CAD severity and LVEF for all-cause mortality and nonfatal myocardial infarction (HR: 1.17; 95% CI: 1.06 to 1.29).

CONCLUSIONS: Using CTA, CAD severity, LVEF, and total plaque score seems to have prognostic and incremental value over routine clinical predictors. Cardiac CTA seems to be a promising noninvasive modality with prognostic value.

PMID: