Association of cardiac events with coronary artery disease detected by 64-slice or greater coronary CT angiography: A systematic review and meta-analysis

doi:10.1016/j.ijcard.2013.08.096

International Journal of Cardiology

Volume 169, Issue 2, 30 October 2013, Pages 112-120

https://doi.org/10.1016/j.ijcard.2013.08.096 Get rights and content

Abstract

Background

The value of ≥ 64-slice coronary CT angiography (CCTA) to determine odds of cardiac death or non-fatal myocardial infarction (MI) needs further clarification.

Methods

We performed a systematic review and meta-analysis using publications reporting events/severity of coronary artery disease (CAD) in patients with suspected CAD undergoing CCTA. Patients were divided into: no CAD, non-obstructive CAD (maximal stenosis < 50%), and obstructive CAD (≥ 50% stenosis). Odds ratios with 95% confidence intervals were calculated using a fixed or random effects model. Heterogeneity was assessed using the I² index.

Results

We included thirty-two studies comprising 41,960 patients with 363 all-cause deaths (15.0%), 114 cardiac deaths (4.7%), 342 MI (14.2%), 69 unstable angina (2.8%), and 1527 late revascularizations (63.2%) over 1.96 (SD 0.77) years of follow-up. Cardiac death or MI occurred in 0.04% without, 1.29% with non-obstructive, and 6.53% with obstructive CAD. OR for cardiac death or MI was: 14.92 (95% CI, 6.78 to 32.85) for obstructive CAD, 6.41 (95% CI, 2.44 to 16.84) for non-obstructive CAD versus no CAD, and 3.19 (95% CI, 2.29 to 4.45) for non-obstructive versus obstructive CAD and 6.56 (95% CI, 3.07 to 14.02) for no versus any CAD. Similar trends were noted for all-cause mortality and composite major adverse cardiovascular events.

Conclusions

Increasing CAD severity detected by CCTA is associated with cardiac death or MI, all-cause mortality, and composite major adverse cardiovascular events. Absence of CAD is associated with very low odds of major adverse events, but non-obstructive disease significantly increases odds of cardiac adverse events in this follow-up period.

Introduction

Coronary heart disease (CHD) is responsible for approximately 1 of every 6 deaths in the United States [1]. Identifying persons at risk for CHD and mitigating modifiable risk factors can reduce a majority of fatal and non-fatal events [2]. The Framingham criteria are traditionally employed to predict the 10-year risk for coronary death or myocardial infarction (MI) [3] or total cardiovascular events [4]. Current day 64-slice or greater coronary CT angiography (CCTA) is reported to have a sensitivity of 93% to 97% and specificity of 80% to 90% compared to standard coronary angiography [5]. Multiple observational studies and three small meta-analyses have suggested that the detection of CAD by CCTA provides predictive information; however, none of these studies has demonstrated an association between cardiac death or MI at each level of CAD severity [6], [7], [8]. Many studies included coronary revascularization, a rather soft end-point, in the calculation of MACE [9], [10], [11], [12], [13]. Several older studies included data obtained by scanners that lack 64-slice or greater technology [6], [7], [8]. In response we conducted a systematic review and meta-analysis to determine the pooled prognostic value of major adverse events in patients with suspected or known coronary artery disease that underwent coronary imaging with a ≥ 64-slice scanner. We hypothesize that current generation CCTA identifies those patients at high risk for subsequent cardiovascular adverse events with incremental severity of detectable CAD.

Section snippets

Data sources and search

A systematic review was conducted using PUBMED, EMBASE, Web of Science and the Cochrane Library. The authors and references of each included article were searched. The construct of the literature search was conducted with the help of a medical librarian. The search terms consisted of: coronary CT or computed tomography or X-ray computed tomography angiography, or coronary angiography, prognosis, survival, death, revascularization, unstable angina, and myocardial infarction. There were no search

Study and patient characteristics

After duplicate records and those meeting the exclusion criteria were removed, 32 studies were included in the qualitative meta-analysis (Fig. 1). There were 4 studies with zero events at all levels of CAD that were not included in the final quantitative meta-analysis [23], [24], [25], [26], [27]. Study and baseline patient characteristics of the 32 studies are presented online in Online Table 1 and Online Table 2. The total population included 41,960 patients with an average of 1.96 (SD 0.77)

Discussion

To date this is the largest and only meta-analysis of CCTA studies using ≥ 64-slice scanners, comprising over 82,000 patient-years of follow-up and > 2000 analyzed events. We demonstrate a robust association between cardiac death or MI, all-cause mortality and composite MACE and the presence and severity of CAD. To our knowledge this is the first meta-analysis to report an association between each level of CAD severity stratified by CCTA and cardiac death or MI.

From an epidemiologic perspective,

Conclusion

We observed a robust association between incremental severity of CAD diagnosed by ≥ 64-slice CCTA and cardiac death or MI, in addition to all-cause mortality and composite MACE in patients with suspected CAD with high risk cardiovascular features or equivocal stress tests followed for an average of approximately 2 years. Despite inherent limitations in this type of study design, an absence of CAD is associated with very low odds of major cardiac events, while even non-obstructive disease is

Conflict of interest

Potential source of conflict: Conflict of interest: Dr. Joel Strom has common stock with the General Electric Company which may represent a potential conflict of interest. The remaining authors have no potential conflicts of interest involving the work under consideration for publication during the time involving the work, from initial conception and planning to present.

Acknowledgment

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

References (0)

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^☆: Financial disclosures: Phillip Habib: grants/grants pending (paid to the institution): University of Florida Health Science Center Jacksonville Dean's Fund Research Award. Jacinta Green: none; Ryan Butterfield: none; Gretchen Kuntz: none; Raguveer Murthy: none; Dale Kraemer: none; Robert Percy: none; Alan Miller: relevant financial activities outside the submitted work: Consultant fees for: St Jude Medical, Medtronic, Cardiomems, Biotronik, Pfizer, NIH, Biocontrol Med. Grants/grants pending (paid to the institution): Clinical Cardiovascular Studies Payment for lectures including service on speakers bureau (paid to individual): North American Center for Continuing Medical Education, and Practice Point Communications. Joel Strom: relevant financial activities outside the submitted work. Consultant fees: University of South Florida, Tampa, FL Consultant on 2 DoD Funded Grants in 2010–2011; Ogden & Sullivan, Tampa, FL Medical-Legal Case Reviews; First Professional Insurance Co. Medical-Legal Case Reviews; MacFarlane, Ferguson & McMullen Medical Legal Case Reviews; LaCava & Jacobson Medical-Legal Case Reviews; Prizm Medical Resources, Ltd. Medical Review; Paul Reviere Companies Medical Review; UNUM Medical Review; Quintairos, Prieto, Wood & Boyer Medical-Legal Case Review. Employment Fees: University of South Florida, Tampa, FL Adjunct Professor, Honors College: 2010–11. Expert Testimony: Trentalange & Kelley, P.A. Deposition, De La Parte & Gilbert, P.A. Deposition; Fogelman & Rosenkoetter, P.A. Trial Testimony; Thompson Goodis Deposition; Ogden & Sullivan Deposition. Stock/Stock options: General Electric Company Common Stock; Pfizer, Inc. Common Stock; Merck & Company, Inc. Common Stock; Abbott Laboratories Common Stock; Bristol Myers Squibb Common Stock.

¹: Each and every author listed above “takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation”.

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Association of cardiac events with coronary artery disease detected by 64-slice or greater coronary CT angiography: A systematic review and meta-analysis☆