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      Prognostic Value of Cardiac Computed Tomography Angiography in Patients with Suspected Coronary Artery Disease: A Meta-Analysis

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          Abstract

          Objectives: The diagnostic accuracy of cardiac computed tomography angiography (CCTA) is well reported. The prognostic value of CCTA has been described in several studies, but many of these were underpowered and an update of the meta-analysis is necessary to increase the power to predict rare events.The purpose of this study was to perform a meta-analysis of the ability of CCTA to predict future cardiovascular events. Methods: We searched multiple databases for longitudinal studies of CCTA with a follow-up of at least 12 months of symptomatic patients with suspected coronary artery disease (CAD) reporting major adverse cardiovascular events (MACE), death, myocardial infarction and revascularization. Summary test parameters and receiver-operating characteristic curves were calculated. Results: Eighteen studies evaluated 29,243 patients with a median follow-up of 25 months. For MACE in patients with negative findings on CCTA, there was a pooled negative likelihood ratio (LR) of 0.01 [95% confidence interval (CI) 0.00-0.08], a positive LR of 1.72 (95% CI 1.54-1.91), a sensitivity of 1.00 (95% CI 0.97-1.00), a specificity of 0.42 (95% CI 0.36-0.48) and a diagnostic odds ratio of 159.07 (95% CI 22.20-1,139.80). The weighted average annualized MACE rate for positive versus negative CCTA findings was 3.49 versus 0.21%. Stratifying by no CAD, nonobstructive CAD or obstructive CAD, there were incrementally increasing adverse events. Conclusions: Adverse cardiovascular events among patients with normal findings on CCTA are rare. There are incrementally increasing future MACE with increasing CAD by CCTA.

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          Most cited references 20

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          Prognostic value of multidetector coronary computed tomographic angiography for prediction of all-cause mortality.

          The purpose of this study was to examine the association of all-cause death with the coronary computed tomographic angiography (CCTA)-defined extent and severity of coronary artery disease (CAD). The prognostic value of identifying CAD by CCTA remains undefined. We examined a single-center consecutive cohort of 1,127 patients > or =45 years old with chest symptoms. Stenosis by CCTA was scored as minimal ( or =70%) for each coronary artery. Plaque was assessed in 3 ways: 1) moderate or obstructive plaque; 2) CCTA score modified from Duke coronary artery score; and 3) simple clinical scores grading plaque extent and distribution. A 15.3 +/- 3.9-month follow-up of all-cause death was assessed using Cox proportional hazards models adjusted for pretest CAD likelihood and risk factors. Deaths were verified by the Social Security Death Index. The CCTA predictors of death included proximal left anterior descending artery stenosis and number of vessels with > or =50% and > or =70% stenosis (all p or =70% or 2 stenoses > or =50% (p = 0.013) to 85% survival for > or =50% LM artery stenosis (p < 0.0001). Clinical scores measuring plaque burden and distribution predicted 5% to 6% higher absolute death rate (6.6% vs. 1.6% and 8.4% vs. 2.5%; p = 0.05 for both). In patients with chest pain, CCTA identifies increased risk for all-cause death. Importantly, a negative CCTA portends an extremely low risk for death.
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            The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis.

            The purpose of this work was to determine the prognostic value of normal exercise myocardial perfusion imaging (MPI) tests and exercise echocardiography tests, and to determine the prognostic value of these imaging modalities in women and men. Exercise MPI and exercise echocardiography provide prognostic information that is useful in the risk stratification of patients with suspected coronary artery disease (CAD). We searched the PubMed, Cochrane, and DARE databases between January 1990 and May 2005, and reviewed bibliographies of articles obtained. We included prospective cohort studies of subjects who underwent exercise MPI or exercise echocardiography for known or suspected CAD, and provided data on primary outcomes of myocardial infarction (MI) and cardiac death with at least 3 months of follow-up. Secondary outcomes (unstable angina, revascularization procedures) were abstracted if provided. Studies performed exclusively in patients with CAD were excluded. The negative predictive value (NPV) for MI and cardiac death was 98.8% (95% confidence interval [CI] 98.5 to 99.0) over 36 months of follow-up for MPI, and 98.4% (95% CI 97.9 to 98.9) over 33 months for echocardiography. The corresponding annualized event rates were 0.45% per year for MPI and 0.54% per year for echocardiography. In subgroup analyses, annualized event rates were <1% for each MPI isotope, and were similar for women and men. For secondary events, MPI and echocardiography had annualized event rates of 1.25% and 0.95%, respectively. Both exercise MPI and exercise echocardiography have high NPVs for primary and secondary cardiac events. The prognostic utility of both modalities is similar for both men and women.
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              Prognostic value of cardiac computed tomography angiography: a systematic review and meta-analysis.

              The purpose of this study was to systematically review and perform a meta-analysis of the ability of cardiac computed tomography angiography (CCTA) to predict future cardiovascular events and death. The diagnostic accuracy of CCTA is well reported. The prognostic value of CCTA has been described in several studies, but many were underpowered. Pooling outcomes increases the power to predict rare events. We searched multiple databases for longitudinal studies of CCTA with at least 3 months follow-up of symptomatic patients with suspected coronary artery disease (CAD) reporting major adverse cardiovascular events (MACE), consisting of death, myocardial infarction (MI), and revascularization. Annualized event rates were pooled using a bivariate mixed-effects binomial regression model to calculate summary likelihood ratios and receiver-operating characteristic curves. Eighteen studies evaluated 9,592 patients with a median follow-up of 20 months. The pooled annualized event rate for obstructive (any vessel with >50% luminal stenosis) versus normal CCTA was 8.8% versus 0.17% per year for MACE (p < 0.05) and 3.2% versus 0.15% for death or MI (p < 0.05). The pooled negative likelihood ratio for MACE after normal CCTA findings was 0.008 (95% confidence interval [CI]: 0.0004 to 0.17, p < 0.001), the positive likelihood ratio was 1.70 (95% CI: 1.42 to 2.02, p < 0.001), sensitivity was 0.99 (95% CI: 0.93 to 1.00, p < 0.001), and specificity was 0.41 (95% CI: 0.31 to 0.52, p < 0.001). Stratifying by no CAD, nonobstructive CAD (worst stenosis <50%), or obstructive CAD, there were incrementally increasing adverse events. Adverse cardiovascular events among patients with normal findings on CCTA are rare. There are incrementally increasing future MACE with increasing CAD by CCTA. Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2014
                July 2014
                05 June 2014
                : 128
                : 4
                : 304-312
                Affiliations
                Departments of aRadiology, bInterventional Radiology and cCardiology, BenQ Medical Center, Nanjing Medical University, Nanjing, PR China
                Author notes
                *Jichen Wang, MD, Department of Radiology, BenQ Medical Center, Nanjing Medical University, 71 Hexi Street, Nanjing, Jiangsu 210019 (PR China), E-Mail fskwjc@126.com
                Article
                360131 Cardiology 2014;128:304-312
                10.1159/000360131
                24903842
                © 2014 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 6, Tables: 2, Pages: 9
                Categories
                Original Research

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