Prognostic significance of calcified plaque among symptomatic patients with nonobstructive coronary artery disease

Sana Shah, Naveen Bellam, Jonathon Leipsic, Daniel S Berman, Arshed Quyyumi, Jörg Hausleiter, Stephan Achenbach, Mouaz Al-Mallah, Matthew J Budoff, Fillippo Cademartiri, Tracy Q Callister, Hyuk-Jae Chang, Benjamin J W Chow, Ricardo C Cury, Augustin J Delago, Allison L Dunning, Gudrun M Feuchtner, Martin Hadamitzky, Ronald P Karlsberg, Philipp A Kaufmann, Fay Y Lin, Kavitha M Chinnaiyan, Erica Maffei, Gilbert L Raff, Todd C Villines, Millie J Gomez, James K Min, Leslee J Shaw
Journal of Nuclear Cardiology: Official Publication of the American Society of Nuclear Cardiology 2014, 21 (3): 453-66

BACKGROUND: Coronary artery calcium (CAC) is a well-established predictor of clinical outcomes for population screening. Limited evidence is available as to its predictive value in symptomatic patients without obstructive coronary artery disease (CAD). The aim of the current study was to assess the prognostic value of CAC scores among symptomatic patients with nonobstructive CAD.

METHODS: From the COronary Computed Tomographic Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter (CONFIRM) registry, 7,200 symptomatic patients with nonobstructive CAD (<50% coronary stenosis) on coronary-computed tomographic angiography were prospectively enrolled and followed for a median of 2.1 years. Patients were categorized as without (0% stenosis) or with (>0% but <50% coronary stenosis) a luminal stenosis. CAC scores were calculated using the Agatston method. Univariable and multivariable Cox proportional hazard models were employed to estimate all-cause mortality and/or myocardial infarction (MI). Four-year death and death or MI rates were 1.9% and 3.3%.

RESULTS: Of the 4,380 patients with no luminal stenosis, 86% had CAC scores of <10 while those with a luminal stenosis had more prevalent and extensive CAC with 31.9% having a CAC score of ≥100. Among patients with no luminal stenosis, CAC was not predictive of all-cause mortality (P = .44). However, among patients with a luminal stenosis, 4-year mortality rates ranged from 0.8% to 9.8% for CAC scores of 0 to ≥400 (P < .0001). The mortality hazard was 6.0 (P = .004) and 13.3 (P < .0001) for patients with a CAC score of 100-399 and ≥400. In patients with a luminal stenosis, CAC remained independently predictive in all-cause mortality (P < .0001) and death or MI (P < .0001) in multivariable models containing CAD risk factors and presenting symptoms.

CONCLUSIONS: CAC allows for the identification of those at an increased hazard for death or MI in symptomatic patients with nonobstructive disease. From the CONFIRM registry, the extent of CAC was an independent estimator of long-term prognosis among symptomatic patients with luminal stenosis and may further define risk and guide preventive strategies in patients with nonobstructive CAD.

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