DECLARATION OF CONFLICT OF INTEREST. Nothing to disclose

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1 DECLARATION OF CONFLICT OF INTEREST Nothing to disclose

2 Prognostic value of multidetector computed tomography coronary angiography in a large population of patients with unknown cardiac disease but suspected coronary artery disease: a longterm follow-up study. Authors: Daniele Andreini MD, Gianluca Pontone MD, Saima Mushtaq MD, Laura Antonioli MD, Erika Bertella MD, Alberto Formenti MD, Sarah Cortinovis MD, Piergiuseppe Agostoni MD, PhD, Giovanni Ballerini MD, Cesare Fiorentini MD, Mauro Pepi MD.

3 BACKGROUND

4 BACKGROUND Abnormal patients: presence of 1 coronary plaque

5 BACKGROUND Non obstructive CAD: 0-50% Obstructive CAD: 50%

6 BACKGROUND

7 BACKGROUND Duke Prognostic CAD Index which details the expected 5-year survival by the extent and severity of CAD

8 BACKGROUND Segment Stenosis Score 0 3 for each segment Total Score: 0 48 Segment Involvement Score segments exhibiting plaque, irrespective of the degreee of stenosis Total Score: 0 16

9 AIM OF THE STUDY To evaluate, with a long-term follow-up, the prognostic role of MDCT-CA in a large population of patients with suspicion of CAD but unknown cardiac disease.

10 STUDY POPULATION Between January 2005 and January 2008, 3421 consecutive patients who presented to the outpatient clinic or admitted to our hospital and were referred for further evaluation (using exercise electrocardiogram, stress echocardiography or invasive coronary angiography) of suspected CAD (new onset of chest pain, elevated cardiovascular risk profile, abnormal stress test results) were considered for inclusion in this study. In all patients, MDCT-CA was performed in addition to the standard clinical workup.

11 STUDY POPULATION: EXCLUSION CRITERIA A total of 2077 patients were excluded due to: - History of CAD (1202 cases, 576 for previous myocardial infarction and 626 for previous coronary revascularization) - Others known cardiac disease (535 cases, 181 for heart failure, 45 for congenital heart disease, 120 for significant valvular heart disease, 59 for cardiomyopaties, 38 for myocarditis, 21 for endocarditis, 71 for ascending aorta aneurysm) - Contraindications to contrast agents (55 cases) - Inability to sustain breath hold (40 cases) - Impaired renal function (100 cases) - Cardiac arrhythmias (145 cases) Analytic study population consisted of 1344 subjects

12 METHODS All MDCT-CA examinations was performed using a 64-slice scanner (VCT, GE Medical Systems, Milwaukee, WI, with 64 x mm collimation and a gantry rotation time of 350 ms.)

13 MDCT-CA DATA analyses -Patients were excluded from the analysis in case of an uninterpretable proximal or mid segment, or more than 3 uninterpretable segments in general. -Each MDCT angiography was evaluated for the following parameters: type of coronary plaque; number of segments with noncalcified, calcified and mixed plaques and with any obstructive plaques; quantification of coronary lesions by visual estimation (normal, mild, moderate, or severe). Moderate and severe stenosis were considered as obstructive lesions. -Patients were categorized into 3 broad categories: normal, nonobstructive CAD (mild lesions) and obstructive CAD (obstructive lesions). -Coronary arteries were also assessed by 3 other distinct methods: two traditional angiographic predictors of mortality (presence of obstructive lesions in major epicardial vessel and a modified Duke prognostic CAD index) and coronary plaque scores (SIS=segment involvement score: 0 to 16; SSS=segment stenoses score: 0 to 48).

14 FOLLOW-UP Follow-up information was obtained by either clinical visits or telephone interviews. The outcome measures were: 1) a composite of all cardiac events (cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization and revascularization) 2) a composite of hard cardiac events (cardiac death, nonfatal myocardial infarction, unstable angina). Of the 1344 patients enrolled, 70 were excluded from the analysis because of the MDCT data set was judged uninterpretable. Of the remaining 1274 patients (mean age 57.6 ± 11.8 years, 52.6% men), clinical follow-up (mean 52 ± 25 months) was obtained for 1196 (94%).

15 UNIVARIATE ANALYSIS: MDCT DATA

16 MULTIVARIATE ANALYSIS

17 Cumulative event free survival rate Cumulative event free survival rate A No CAD Nonobstructive CAD ALL EVENTS Obstructive CAD B No CAD Nonobstructive CAD Obstructive CAD HARD EVENTS Time in months

18 Cumulative event free survival rate Cumulative event free survival rate A Non-obstructive CAD 1-vessel CAD 2-vessel CAD 3-vessel CAD LMA CAD HARD EVENTS B Duke 1 Duke 2 Duke 3 Duke 4 and Duke 5 Duke 6 HARD EVENTS Time in months 17

19 Cumulative event free survival rate Cumulative event free survival rate A SSS 5 B ALL EVENTS SSS > 5 SSS 5 SSS > 5 HARD EVENTS Time in months

20 Cumulative event free survival rate Cumulative event free survival rate A SIS 5 B ALL EVENTS SIS > 5 SIS 5 SIS > 5 HARD EVENTS Time in months

21 PROGNOSTIC VALUE OF NON-OBSTRUCTIVE CAD Vulnerable plaques may occur across the full spectrum of severity of stenosis, underlining that also nonobstructive lesions may contribute to coronary events Giroud D Am J Cardiol 1992; Davies MJ Br Heart J % of myocardial infarctions were attributable to socalled angiographically silent lesions (narrowing<50%), whereas only 14% could be assigned to a severe stenotic lesion (>70%) Falk E Circulation 1995

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23 Patient CONCLUSIONS 0% 50% 70% 100% No symptoms No symptoms Symptoms CT - Stress Test CT + Stress Test CT + Stress Test + AMI Good prognosis Worse prognosis Worse prognosis No therapy Therapy (?) Therapy Early identification of these patients could be crucial: Clinical management of these patients could be changed in terms of: 1. shorter clinical or instrumental follow-up 2. more aggressive strategy on CV risk factors 3. to optimize medical therapy