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Atherosclerosis. 2014 Feb;232(2):298-304. doi: 10.1016/j.atherosclerosis.2013.09.025. Epub 2013 Oct 29.

Incremental prognostic value of coronary computed tomographic angiography over coronary artery calcium score for risk prediction of major adverse cardiac events in asymptomatic diabetic individuals.

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  • 1Department of Radiology, Weill Cornell Medical College and The NewYork-Presbyterian Hospital, New York, NY, USA. Electronic address:
  • 2Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
  • 3Department of Medicine, University of Erlangen, Erlangen, Germany.
  • 4Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, MI, USA.
  • 5Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA, USA.
  • 6Department of Radiology, Giovanni XXIII Hospital, Monastier, Treviso, Italy; Department of Radiology, Erasmus Medical Center, Rotterdam, Netherlands.
  • 7Tennessee Heart and Vascular Institute, Hendersonville, TN, USA.
  • 8Division of Cardiology, Severance Cardiovascular Hospital, Seoul, South Korea.
  • 9William Beaumont Hospital, Royal Oak, MI, USA.
  • 10Department of Medicine and Radiology, University of Ottawa, Ontario, Canada.
  • 11Baptist Cardiac and Vascular Institute, Miami, FL, USA.
  • 12Capitol Cardiology Associates, Albany, NY, USA.
  • 13Department of Public Health, Weill Cornell Medical College, New York, NY, USA.
  • 14Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
  • 15University of Munich, Munich, Germany.
  • 16Cardiovascular Medical Group, Los Angeles, CA, USA.
  • 17University Hospital, Zurich, Switzerland.
  • 18Seoul National University Hospital, Seoul, South Korea.
  • 19Department of Medicine and Radiology, University of British Columbia, Vancouver, BC, Canada.
  • 20Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
  • 21Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
  • 22Walter Reed Medical Center, Bethesda, MD, USA.



Coronary artery disease (CAD) diagnosis by coronary computed tomographic angiography (CCTA) is useful for identification of symptomatic diabetic individuals at heightened risk for death. Whether CCTA-detected CAD enables improved risk assessment of asymptomatic diabetic individuals beyond clinical risk factors and coronary artery calcium scoring (CACS) remains unexplored.


From a prospective 12-center international registry of 27,125 individuals undergoing CCTA, we identified 400 asymptomatic diabetic individuals without known CAD. Coronary stenosis by CCTA was graded as 0%, 1-49%, 50-69%, and ≥70%. CAD was judged on a per-patient, per-vessel and per-segment basis as maximal stenosis severity, number of vessels with ≥50% stenosis, and coronary segments weighted for stenosis severity (segment stenosis score), respectively. We assessed major adverse cardiovascular events (MACE) - inclusive of mortality, nonfatal myocardial infarction (MI), and late target vessel revascularization ≥90 days (REV) - and evaluated the incremental utility of CCTA for risk prediction, discrimination and reclassification.


Mean age was 60.4 ± 9.9 years; 65.0% were male. At a mean follow-up 2.4 ± 1.1 years, 33 MACE occurred (13 deaths, 8 MI, 12 REV) [8.25%; annualized rate 3.4%]. By univariate analysis, per-patient maximal stenosis [hazards ratio (HR) 2.24 per stenosis grade, 95% confidence interval (CI) 1.61-3.10, p < 0.001], increasing numbers of obstructive vessels (HR 2.30 per vessel, 95% CI 1.75-3.03, p < 0.001) and segment stenosis score (HR 1.14 per segment, 95% CI 1.09-1.19, p < 0.001) were associated with increased MACE. After adjustment for CAD risk factors and CACS, maximal stenosis (HR 1.80 per grade, 95% CI 1.18-2.75, p = 0.006), number of obstructive vessels (HR 1.85 per vessel, 95% CI 1.29-2.65, p < 0.001) and segment stenosis score (HR 1.11 per segment, 95% CI 1.05-1.18, p < 0.001) were associated with increased risk of MACE. Beyond age, gender and CACS (C-index 0.64), CCTA improved discrimination by maximal stenosis, number of obstructive vessels and segment stenosis score (C-index 0.77, 0.77 and 0.78, respectively). Similarly, CCTA findings improved risk reclassification by per-patient maximal stenosis [integrated discrimination improvement (IDI) index 0.03, p = 0.03] and number of obstructive vessels (IDI index 0.06, p = 0.002), and by trend for segment stenosis score (IDI 0.03, p = 0.06).


For asymptomatic diabetic individuals, CCTA measures of CAD severity confer incremental risk prediction, discrimination and reclassification on a per-patient, per-vessel and per-segment basis.

Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.


Coronary CT angiography; Coronary artery calcium score; Coronary artery disease; Major adverse cardiac events

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