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Prognostic Value of Coronary CT Angiography for Predicting Poor Cardiac Outcome in Stroke Patients without Known Cardiac Disease or Chest Pain: The Assessment of Coronary Artery Disease in Stroke Patients Study

  • Sung Hyun Yoon (Department of Radiology, Seoul National University Bundang Hospital) ;
  • Eunhee Kim (Department of Radiology, Ewha Womans University Mokdong Hospital) ;
  • Yongho Jeon (Department of Applied Statistics, College of Business and Economics, Yonsei University) ;
  • Sang Yoon Yi (Department of Applied Statistics, College of Business and Economics, Yonsei University) ;
  • Hee-Joon Bae (Department of Neurology, Seoul National University Bundang Hospital) ;
  • Ik-Kyung Jang (Cardiology Division, Massachusetts General Hospital, Harvard Medical School) ;
  • Joo Myung Lee (Department of Internal Medicine, Samsung Medical Center) ;
  • Seung Min Yoo (Department of Radiology, CHA University Bundang Medical Center) ;
  • Charles S. White (Department of Radiology, University of Maryland) ;
  • Eun Ju Chun (Department of Radiology, Seoul National University Bundang Hospital)
  • Received : 2020.02.08
  • Accepted : 2020.04.28
  • Published : 2020.09.01

Abstract

Objective: To assess the incremental prognostic value of coronary computed tomography angiography (CCTA) in comparison to a clinical risk model (Framingham risk score, FRS) and coronary artery calcium score (CACS) for future cardiac events in ischemic stroke patients without chest pain. Materials and Methods: This retrospective study included 1418 patients with acute stroke who had no previous cardiac disease and underwent CCTA, including CACS. Stenosis degree and plaque types (high-risk, non-calcified, mixed, or calcified plaques) were assessed as CCTA variables. High-risk plaque was defined when at least two of the following characteristics were observed: low-density plaque, positive remodeling, spotty calcification, or napkin-ring sign. We compared the incremental prognostic value of CCTA for major adverse cardiovascular events (MACE) over CACS and FRS. Results: The prevalence of any plaque and obstructive coronary artery disease (CAD) (stenosis ≥ 50%) were 70.7% and 30.2%, respectively. During the median follow-up period of 48 months, 108 patients (7.6%) experienced MACE. Increasing FRS, CACS, and stenosis degree were positively associated with MACE (all p < 0.05). Patients with high-risk plaque type showed the highest incidence of MACE, followed by non-calcified, mixed, and calcified plaque, respectively (log-rank p < 0.001). Among the prediction models for MACE, adding stenosis degree to FRS showed better discrimination and risk reclassification compared to FRS or the FRS + CACS model (all p < 0.05). Furthermore, incorporating plaque type in the prediction model significantly improved reclassification (integrated discrimination improvement, 0.08; p = 0.023) and showed the highest discrimination index (C-statistics, 0.85). However, the addition of CACS on CCTA with FRS did not add to the prediction ability for MACE (p > 0.05). Conclusion: Assessment of stenosis degree and plaque type using CCTA provided additional prognostic value over CACS and FRS to risk stratify stroke patients without prior history of CAD better.

Keywords

Acknowledgement

This work was supported by grant No. 12-2013-024 from the SNUBH Research Fund and the National Research Foundation grant NRF2010-0023504 funded by the Korea government (MEST).

References

  1. Hankey GJ, Jamrozik K, Broadhurst RJ, Forbes S, Burvill PW, Anderson CS, et al. Five-year survival after first-ever stroke and related prognostic factors in the Perth Community Stroke Study. Stroke 2000;31:2080-2086  https://doi.org/10.1161/01.STR.31.9.2080
  2. Dhamoon MS, Sciacca RR, Rundek T, Sacco RL, Elkind MS. Recurrent stroke and cardiac risks after first ischemic stroke: the Northern Manhattan Study. Neurology 2006;66:641-646  https://doi.org/10.1212/01.wnl.0000201253.93811.f6
  3. Roberts CS, Gorelick PB, Ye X, Harley C, Goldberg GA. Additional stroke-related and non-stroke-related cardiovascular costs and hospitalizations in managed-care patients after ischemic stroke. Stroke 2009;40:1425-1432  https://doi.org/10.1161/STROKEAHA.108.534354
  4. Gongora-Rivera F, Labreuche J, Jaramillo A, Steg PG, Hauw JJ, Amarenco P. Autopsy prevalence of coronary atherosclerosis in patients with fatal stroke. Stroke 2007;38:1203-1210  https://doi.org/10.1161/01.STR.0000260091.13729.96
  5. Seo WK, Yong HS, Koh SB, Suh SI, Kim JH, Yu SW, et al. Correlation of coronary artery atherosclerosis with atherosclerosis of the intracranial cerebral artery and the extracranial carotid artery. Eur Neurol 2008;59:292-298  https://doi.org/10.1159/000121418
  6. Amarenco P, Lavallee PC, Labreuche J, Ducrocq G, Juliard JM, Feldman L, et al. Prevalence of coronary atherosclerosis in patients with cerebral infarction. Stroke 2011;42:22-29  https://doi.org/10.1161/STROKEAHA.110.584086
  7. Adams RJ, Chimowitz MI, Alpert JS, Awad IA, Cerqueria MD, Fayad P, et al. Coronary risk evaluation in patients with transient ischemic attack and ischemic stroke: a scientific statement for healthcare professionals from the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association. Circulation 2003;108:1278-1290  https://doi.org/10.1161/01.CIR.0000090444.87006.CF
  8. Min JK, Dunning A, Lin FY, Achenbach S, Al-Mallah M, Budoff MJ, et al. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM (COronary CT Angiography Evaluation For Clinical Outcomes: an InteRnational Multicenter Registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol 2011;58:849-860  https://doi.org/10.1016/j.jacc.2011.02.074
  9. Hadamitzky M, Taubert S, Deseive S, Byrne RA, Martinoff S, Schomig A, et al. Prognostic value of coronary computed tomography angiography during 5 years of follow-up in patients with suspected coronary artery disease. Eur Heart J 2013;34:3277-3285  https://doi.org/10.1093/eurheartj/eht293
  10. Ahmadi N, Nabavi V, Hajsadeghi F, Flores F, French WJ, Mao SS, et al. Mortality incidence of patients with non-obstructive coronary artery disease diagnosed by computed tomography angiography. Am J Cardiol 2011;107:10-16  https://doi.org/10.1016/j.amjcard.2010.08.034
  11. Calvet D, Song D, Yoo J, Turc G, Sablayrolles JL, Choi BW, et al. Predicting asymptomatic coronary artery disease in patients with ischemic stroke and transient ischemic attack: the PRECORIS score. Stroke 2014;45:82-86  https://doi.org/10.1161/STROKEAHA.113.003414
  12. Ahn SS, Nam HS, Heo JH, Kim YD, Lee SK, Han KH, et al. Ischemic stroke: measurement of intracranial artery calcifications can improve prediction of asymptomatic coronary artery disease. Radiology 2013;268:842-849  https://doi.org/10.1148/radiol.13122417
  13. Anderson KM, Odell PM, Wilson PW, Kannel WB. Cardiovascular disease risk profiles. Am Heart J 1991;121:293-298  https://doi.org/10.1016/0002-8703(91)90861-B
  14. Maurovich-Horvat P, Ferencik M, Voros S, Merkely B, Hoffmann U. Comprehensive plaque assessment by coronary CT angiography. Nat Rev Cardiol 2014;11:390-402  https://doi.org/10.1038/nrcardio.2014.60
  15. Amarenco P, Lavallee PC, Labreuche J, Ducrocq G, Juliard JM, Feldman L, et al. Coronary artery disease and risk of major vascular events after cerebral infarction. Stroke 2013;44:1505-1511  https://doi.org/10.1161/STROKEAHA.111.000142
  16. Touze E, Varenne O, Chatellier G, Peyrard S, Rothwell PM, Mas JL. Risk of myocardial infarction and vascular death after transient ischemic attack and ischemic stroke: a systematic review and meta-analysis. Stroke 2005;36:2748-2755  https://doi.org/10.1161/01.STR.0000190118.02275.33
  17. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol 2018;72:2231-2264  https://doi.org/10.1016/j.jacc.2018.08.1038
  18. Hadamitzky M, Meyer T, Hein F, Bischoff B, Martinoff S, Schomig A, et al. Prognostic value of coronary computed tomographic angiography in asymptomatic patients. Am J Cardiol 2010;105:1746-1751  https://doi.org/10.1016/j.amjcard.2010.01.354
  19. Calvet D, Touze E, Varenne O, Sablayrolles JL, Weber S, Mas JL. Prevalence of asymptomatic coronary artery disease in ischemic stroke patients: the PRECORIS study. Circulation 2010;121:1623-1629  https://doi.org/10.1161/CIRCULATIONAHA.109.906958
  20. Hur J, Lee KH, Hong SR, Suh YJ, Hong YJ, Lee HJ, et al. Prognostic value of coronary computed tomography angiography in stroke patients. Atherosclerosis 2015;238:271-277  https://doi.org/10.1016/j.atherosclerosis.2014.10.102
  21. Steg PG, Bhatt DL, Wilson PW, D'Agostino R Sr, Ohman EM, Rother J, et al. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA 2007;297:1197-1206  https://doi.org/10.1001/jama.297.11.1197
  22. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497  https://doi.org/10.1001/jama.285.19.2486
  23. Towfighi A, Markovic D, Ovbiagele B. Utility of Framingham coronary heart disease risk score for predicting cardiac risk after stroke. Stroke 2012;43:2942-2947  https://doi.org/10.1161/STROKEAHA.112.668319
  24. Schlendorf KH, Nasir K, Blumenthal RS. Limitations of the Framingham risk score are now much clearer. Prev Med 2009;48:115-116  https://doi.org/10.1016/j.ypmed.2008.12.002
  25. Polonsky TS, McClelland RL, Jorgensen NW, Bild DE, Burke GL, Guerci AD, et al. Coronary artery calcium score and risk classification for coronary heart disease prediction. JAMA 2010;303:1610-1616  https://doi.org/10.1001/jama.2010.461
  26. Rubinshtein R, Gaspar T, Halon DA, Goldstein J, Peled N, Lewis BS. Prevalence and extent of obstructive coronary artery disease in patients with zero or low calcium score undergoing 64-slice cardiac multidetector computed tomography for evaluation of a chest pain syndrome. Am J Cardiol 2007;99:472-475  https://doi.org/10.1016/j.amjcard.2006.08.060
  27. van Werkhoven JM, de Boer SM, Schuijf JD, Cademartiri F, Maffei E, Jukema JW, et al. Impact of clinical presentation and pretest likelihood on the relation between calcium score and computed tomographic coronary angiography. Am J Cardiol 2010;106:1675-1679  https://doi.org/10.1016/j.amjcard.2010.08.014
  28. Rothwell PM, Gibson R, Warlow CP. Interrelation between plaque surface morphology and degree of stenosis on carotid angiograms and the risk of ischemic stroke in patients with symptomatic carotid stenosis. On behalf of the European Carotid Surgery Trialists' Collaborative Group. Stroke 2000;31:615-621  https://doi.org/10.1161/01.STR.31.3.615
  29. Motoyama S, Kondo T, Sarai M, Sugiura A, Harigaya H, Sato T, et al. Multislice computed tomographic characteristics of coronary lesions in acute coronary syndromes. J Am Coll Cardiol 2007;50:319-326  https://doi.org/10.1016/j.jacc.2007.03.044
  30. Puchner SB, Liu T, Mayrhofer T, Truong QA, Lee H, Fleg JL, et al. High-risk plaque detected on coronary CT angiography predicts acute coronary syndromes independent of significant stenosis in acute chest pain: results from the ROMICAT-II trial. J Am Coll Cardiol 2014;64:684-692  https://doi.org/10.1016/j.jacc.2014.05.039
  31. Litmanovich DE, Tack DM, Shahrzad M, Bankier AA. Dose reduction in cardiothoracic CT: review of currently available methods. Radiographics 2014;34:1469-1489  https://doi.org/10.1148/rg.346140084
  32. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in acute stroke treatment. Stroke 1993;24:35-41 https://doi.org/10.1161/01.STR.24.1.35