[KSCI] Korea Science Citation Index Service

http://dx.doi.org/10.4250/jcu.2015.23.4.244

DIFFERENTIAL PROGNOSTIC VALUE OF CORONARY COMPUTED TOMOGRAPHY ANGIOGRAPHY IN RELATION TO EXERCISE ELECTROCARDIOGRAPHY IN ASYMPTOMATIC SUBJECTS

Lee, Sang-Eun (Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System)
Cho, Iksung (Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System)
Hong, Geu-Ru (Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System)
Chang, Hyuk-Jae (Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System)
Sung, Ji Min (Department of Research Affairs, Yonsei University College of Medicine, Yonsei University Health System)
Cho, In-Jeong (Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System)
Shim, Chi Young (Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System)
Choi, Byoung Wook (Division of Radiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine)
Chung, Namsik (Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System)

Publication Information

Journal of Cardiovascular Imaging / v.23, no.4, 2015 , pp. 244-252 More about this Journal

Abstract

BACKGROUND: To explore the prognostic performance of coronary computed tomography angiography (CCTA) and exercise electrocardiography (XECG) in asymptomatic subjects. METHODS: We retrospectively enrolled 812 ( $59{\pm}9years$ , 60.8% male) asymptomatic subjects who underwent CCTA and XECG concurrently from 2003 through 2009. Subjects were followed-up for major adverse cardiac events (MACE) including cardiac death, nonfatal myocardial infarction, unstable angina, and revascularization after 90 days from index CCTA. RESULTS: The prevalence of occult coronary artery disease (CAD) detected by CCTA was 17.5% and 120 subjects (14.8%) had positive XECG. During a mean follow-up of $37{\pm}16months$ , nine subjects experienced MACE. In multivariable Cox-regression analysis, only the presence of CAD by CCTA independently predicted future MACE (p = 0.002). Moreover, CAD by CCTA improved the predictive value when added to a clinical risk factor model using the likelihood ratio test (p < 0.001). Notably, the prognostic value of CCTA persisted in the moderate-to-high-risk group as classified by the Duke treadmill score (p = 0.040), but not in the low-risk group (p = 0.991). CONCLUSION: CCTA provides incremental prognostic benefit over and above XECG in an asymptomatic population, especially for those in a moderate-to-high-risk group as classified by the Duke treadmill score. Risk stratification using XECG may prove valuable for identifying asymptomatic subjects who can benefit from CCTA.

Keywords

Coronary artery disease; Coronary computed tomography angiography; Exercise electrocardiography; Asymptomatic population;

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Reference

1	Gibbons RJ, Jones DW, Gardner TJ, Goldstein LB, Moller JH, Yancy CW; American Heart Association. The American Heart Association’s 2008 statement of principles for healthcare reform. Circulation 2008;118:2209-18. DOI
2	Christopher Jones R, Pothier CE, Blackstone EH, Lauer MS. Prognostic importance of presenting symptoms in patients undergoing exercise testing for evaluation of known or suspected coronary disease. Am J Med 2004;117:380-9. DOI
3	O’Malley PG, Redberg RF. Risk refinement, reclassification, and treatment thresholds in primary prevention of cardiovascular disease: incremental progress but significant gaps remain. Arch Intern Med 2010;170:1602-3.
4	Aktas MK, Ozduran V, Pothier CE, Lang R, Lauer MS. Global risk scores and exercise testing for predicting all-cause mortality in a preventive medicine program. JAMA 2004;292:1462-8. DOI
5	Goraya TY, Jacobsen SJ, Pellikka PA, Miller TD, Khan A, Weston SA, Gersh BJ, Roger VL. Prognostic value of treadmill exercise testing in elderly persons. Ann Intern Med 2000;132:862-70.
6	Mark DB, Shaw L, Harrell FE Jr, Hlatky MA, Lee KL, Bengtson JR, McCants CB, Califf RM, Pryor DB. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 1991;325:849-53. DOI
7	Cho I, Shim J, Chang HJ, Sung JM, Hong Y, Shim H, Kim YJ, Choi BW, Min JK, Kim JY, Shim CY, Hong GR, Chung N. Prognostic value of multidetector coronary computed tomography angiography in relation to exercise electrocardiogram in patients with suspected coronary artery disease. J Am Coll Cardiol 2012;60:2205-15. DOI
8	Cho I, Min HS, Chun EJ, Park SK, Choi Y, Blumenthal RS, Rivera JJ, Nasir K, Kim YJ, Sohn DW, Oh BH, Park YB, Chang HJ. Coronary atherosclerosis detected by coronary CT angiography in asymptomatic subjects with early chronic kidney disease. Atherosclerosis 2010;208:406-11. DOI
9	Choi EK, Choi SI, Rivera JJ, Nasir K, Chang SA, Chun EJ, Kim HK, Choi DJ, Blumenthal RS, Chang HJ. Coronary computed tomography angiography as a screening tool for the detection of occult coronary artery disease in asymptomatic individuals. J Am Coll Cardiol 2008;52:357-65. DOI
10	Djaberi R, Schuijf JD, Boersma E, Kroft LJ, Pereira AM, Romijn JA, Scholte AJ, Jukema JW, Bax JJ. Differences in atherosclerotic plaque burden and morphology between type 1 and 2 diabetes as assessed by multislice computed tomography. Diabetes Care 2009;32:1507-12. DOI
11	Froelicher VF Jr, Thomas MM, Pillow C, Lancaster MC. Epidemiologic study of asymptomatic men screened by maximal treadmill testing for latent coronary artery disease. Am J Cardiol 1974;34:770-6. DOI
12	Hachamovitch R, Nutter B, Hlatky MA, Shaw LJ, Ridner ML, Dorbala S, Beanlands RS, Chow BJ, Branscomb E, Chareonthaitawee P, Weigold WG, Voros S, Abbara S, Yasuda T, Jacobs JE, Lesser J, Berman DS, Thomson LE, Raman S, Heller GV, Schussheim A, Brunken R, Williams KA, Farkas S, Delbeke D, Schoepf UJ, Reichek N, Rabinowitz S, Sigman SR, Patterson R, Corn CR, White R, Kazerooni E, Corbett J, Bokhari S, Machac J, Guarneri E, Borges-Neto S, Millstine JW, Caldwell J, Arrighi J, Hoffmann U, Budoff M, Lima J, Johnson JR, Johnson B, Gaber M, Williams JA, Foster C, Hainer J, Di Carli MF; SPARC Investigators. Patient management after noninvasive cardiac imaging results from SPARC (Study of myocardial perfusion and coronary anatomy imaging roles in coronary artery disease). J Am Coll Cardiol 2012;59:462-74. DOI
13	Gibson RS, Beller GA. Should exercise electrocardiographic testing be replaced by radioisotope methods? Cardiovasc Clin 1983;13:1-31.
14	Podrid PJ, Graboys TB, Lown B. Prognosis of medically treated patients with coronary-artery disease with profound ST-segment depression during exercise testing. N Engl J Med 1981;305:1111-6. DOI
15	Mora S, Redberg RF, Cui Y, Whiteman MK, Flaws JA, Sharrett AR, Blumenthal RS. Ability of exercise testing to predict cardiovascular and all-cause death in asymptomatic women: a 20-year follow-up of the lipid research clinics prevalence study. JAMA 2003;290:1600-7.
16	Li S, Liu J, Luo Y, Peng L, Ni Q, Wu H, Wang C, Chen L, Dong R, Zhu J. Diagnostic accuracy of noninvasive coronary angiography with 320-slice computed tomography in the clinical routine: results from four-year clinical registry at a single center. Int J Cardiol 2013;168:5035-6. DOI
17	Nucifora G, Schuijf JD, van Werkhoven JM, Jukema JW, Djaberi R, Scholte AJ, de Roos A, Schalij MJ, van der Wall EE, Bax JJ. Prevalence of coronary artery disease across the Framingham risk categories: coronary artery calcium scoring and MSCT coronary angiography. J Nucl Cardiol 2009;16:368-75. DOI
18	Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB 3rd, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR Jr, Smith SC Jr, Spertus JA, Williams SV; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines; American College of Physicians; American Association for Thoracic Surgery; Preventive Cardiovascular Nurses Association; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012;60:e44-164. DOI
19	Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, Foster E, Hlatky MA, Hodgson JM, Kushner FG, Lauer MS, Shaw LJ, Smith SC Jr, Taylor AJ, Weintraub WS, Wenger NK, Jacobs AK, Smith SC Jr, Anderson JL, Albert N, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Nishimura R, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW; American College of Cardiology Foundation; American Heart Association. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2010;56:e50-103. DOI
20	Detrano R, Gianrossi R, Froelicher V. The diagnostic accuracy of the exercise electrocardiogram: a meta-analysis of 22 years of research. Prog Cardiovasc Dis 1989;32:173-206. DOI
21	Zeina AR, Odeh M, Rosenschein U, Zaid G, Barmeir E. Coronary artery disease among asymptomatic diabetic and nondiabetic patients undergoing coronary computed tomography angiography. Coron Artery Dis 2008;19:37-41. DOI
22	Kwon SW, Kim YJ, Shim J, Sung JM, Han ME, Kang DW, Kim JY, Choi BW, Chang HJ. Coronary artery calcium scoring does not add prognostic value to standard 64-section CT angiography protocol in low-risk patients suspected of having coronary artery disease. Radiology 2011;259:92-9. DOI
23	Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O'Reilly MG, Winters WL, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee to Update the 1997 Exercise Testing Guidelines. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002;40:1531-40. DOI
24	Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med 2002;346:793-801. DOI
25	Dedic A, Genders TS, Ferket BS, Galema TW, Mollet NR, Moelker A, Hunink MG, de Feyter PJ, Nieman K. Stable angina pectoris: head-to-head comparison of prognostic value of cardiac CT and exercise testing. Radiology 2011;261:428-36. DOI
26	Chang HJ, Chung N. Clinical perspective of coronary computed tomographic angiography in diagnosis of coronary artery disease. Circ J 2011;75:246-52. DOI
27	Fujimoto S, Kondo T, Kodama T, Orihara T, Sugiyama J, Kondo M, Endo A, Fukazawa H, Nagaoka H, Oida A, Ikeda T, Yamazaki J, Takase S, Narula J. Coronary computed tomography angiography-based coronary risk stratification in subjects presenting with no or atypical symptoms. Circ J 2012;76:2419-25. DOI
28	Dewey M, Dubel HP, Schink T, Baumann G, Hamm B. Head-to-head comparison of multislice computed tomography and exercise electrocardiography for diagnosis of coronary artery disease. Eur Heart J 2007;28:2485-90. DOI
29	Shaw LJ, Raggi P, Schisterman E, Berman DS, Callister TQ. Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiology 2003;228:826-33. DOI
30	Mollet NR, Cademartiri F, van Mieghem CA, Runza G, McFadden EP, Baks T, Serruys PW, Krestin GP, de Feyter PJ. High-resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography. Circulation 2005;112:2318-23. DOI
31	Hadamitzky M, Distler R, Meyer T, Hein F, Kastrati A, Martinoff S, Schomig A, Hausleiter J. Prognostic value of coronary computed tomographic angiography in comparison with calcium scoring and clinical risk scores. Circ Cardiovasc Imaging 2011;4:16-23. DOI
32	Gibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF, Froelicher VF, Mark DB, Marwick TH, McCallister BD, Thompson PD Jr, Winters WL, Yanowitz FG, Ritchie JL, Gibbons RJ, Cheitlin MD, Eagle KA, Gardner TJ, Garson A Jr, Lewis RP, O'Rourke RA, Ryan TJ. ACC/AHA Guidelines for Exercise Testing. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol 1997;30:260-311. DOI
33	Mark DB, Hlatky MA, Harrell FE Jr, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med 1987;106:793-800. DOI
34	Hadamitzky M, Freissmuth B, Meyer T, Hein F, Kastrati A, Martinoff S, Schomig A, Hausleiter J. Prognostic value of coronary computed tomographic angiography for prediction of cardiac events in patients with suspected coronary artery disease. JACC Cardiovasc Imaging 2009;2:404-11. DOI
35	Nishime EO, Cole CR, Blackstone EH, Pashkow FJ, Lauer MS. Heart rate recovery and treadmill exercise score as predictors of mortality in patients referred for exercise ECG. JAMA 2000;284:1392-8. DOI
36	Cho I, Chang HJ, Sung JM, Pencina MJ, Lin FY, Dunning AM, Achenbach S, Al-Mallah M, Berman DS, Budoff MJ, Callister TQ, Chow BJ, Delago A, Hadamitzky M, Hausleiter J, Maffei E, Cademartiri F, Kaufmann P, Shaw LJ, Raff GL, Chinnaiyan KM, Villines TC, Cheng V, Nasir K, Gomez M, Min JK; CONFIRM Investigators. Coronary computed tomographic angiography and risk of allcause mortality and nonfatal myocardial infarction in subjects without chest pain syndrome from the CONFIRM Registry (coronary CT angiography evaluation for clinical outcomes: an international multicenter registry). Circulation 2012;126:304-13. DOI
37	Muhlestein JB, Lappe DL, Lima JA, Rosen BD, May HT, Knight S, Bluemke DA, Towner SR, Le V, Bair TL, Vavere AL, Anderson JL. Effect of screening for coronary artery disease using CT angiography on mortality and cardiac events in high-risk patients with diabetes: the FACTOR-64 randomized clinical trial. JAMA 2014;312:2234-43. DOI
38	Jakobs TF, Becker CR, Ohnesorge B, Flohr T, Suess C, Schoepf UJ, Reiser MF. Multislice helical CT of the heart with retrospective ECG gating: reduction of radiation exposure by ECG-controlled tube current modulation. Eur Radiol 2002;12:1081-6. DOI
39	Marwick TH, Case C, Vasey C, Allen S, Short L, Thomas JD. Prediction of mortality by exercise echocardiography: a strategy for combination with the duke treadmill score. Circulation 2001;103:2566-71. DOI