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Coronary artery disease
Original research article
Prognostic value of chronic total occlusions detected on coronary computed tomographic angiography
  1. Maksymilian P Opolski1,
  2. Heidi Gransar2,
  3. Yao Lu3,
  4. Stephan Achenbach4,
  5. Mouaz H Al-Mallah5,
  6. Daniele Andreini6,
  7. Jeroen J Bax7,
  8. Daniel S Berman6,
  9. Matthew J Budoff8,
  10. Filippo Cademartiri9,
  11. Tracy Q Callister10,
  12. Hyuk-Jae Chang11,
  13. Kavitha Chinnaiyan12,
  14. Benjamin JW Chow13,
  15. Ricardo C Cury14,
  16. Augustin DeLago15,
  17. Gudrun M Feuchtner16,
  18. Martin Hadamitzky17,
  19. Joerg Hausleiter18,
  20. Philipp A Kaufmann19,
  21. Yong-Jin Kim20,
  22. Jonathon A Leipsic21,
  23. Erica C Maffei22,
  24. Hugo Marques23,
  25. Gianluca Pontone6,
  26. Gilbert Raff12,
  27. Ronen Rubinshtein24,
  28. Leslee J Shaw25,
  29. Todd C Villines26,
  30. Millie Gomez3,
  31. Erica C Jones3,
  32. Jessica M Peña3,
  33. James K Min3,
  34. Fay Y Lin3
  1. 1 Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
  2. 2 Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA
  3. 3 Dalio Institute of Cardiovacular Imaging, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, USA
  4. 4 Department of Medicine, University of Erlangen, Erlangen, Germany
  5. 5 King Abdullah International Medical Research Center, King AbdulAziz Cardiac Center, Riyadh, Saudi Arabia
  6. 6 Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS Milan, Milan, Italy
  7. 7 Department of Cardiology, Leiden University Medical Center, HARTZ, Leiden, The Netherlands
  8. 8 Department of Medicine, Harbor UCLA Medical Center, Los Angeles, California, USA
  9. 9 Department of Radiology, SDN IRCCS Cardiovascular Imaging Center, Naples, Italy
  10. 10 Tennessee Heart and Vascular Institute, Hendersonville, Tennessee, USA
  11. 11 Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea
  12. 12 Department of Cardiology, William Beaumont Hospital, Royal Oaks, Michigan, USA
  13. 13 Department of Medicine and Radiology, University of Ottawa, Ottawa, Ontario, Canada
  14. 14 Department of Radiology, Baptist Cardiac and Vascular Institute, Miami, Florida, USA
  15. 15 Capital Cardiology Associates, Albany, New York, USA
  16. 16 Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
  17. 17 Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany
  18. 18 Medizinische Klinik I der Ludwig-Maximilians-Universität München, Munich, Germany
  19. 19 University Hospital, Zurich, Switzerland
  20. 20 Seoul National University Hospital, Seoul, Republic of Korea
  21. 21 Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
  22. 22 Department of Radiology, Area Vasta 1/ASUR Marche, Urbino, Italy
  23. 23 UNICA, Unit of Cardiovascular Imaging, Hospital da Luz, Lisboa, Portugal
  24. 24 Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
  25. 25 Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
  26. 26 Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
  1. Correspondence to Dr James K Min, Dalio Institute of Cardiovascular Imaging, Presbyterian Hospital and Weill Cornell Medical College, 413 East 69th Street, New York USA; jkm2001{at}med.cornell.edu

Abstract

Objective Data describing clinical relevance of chronic total occlusion (CTO) identified by coronary CT angiography (CCTA) have not been reported to date. We investigated the prognosis of CTO on CCTA.

Methods We identified 22 828 patients without prior known coronary artery disease (CAD), who were followed for a median of 26 months. Based on CCTA, coronary lesions were graded as normal (no atherosclerosis), non-obstructive (1%–49%), moderate-to-severe (50%–99%) or totally occluded (100%). All-cause mortality, and major adverse cardiac events defined as mortality, non-fatal myocardial infarction and late coronary revascularisation (≥90 days after CCTA) were assessed.

Results The distribution of patients with normal coronaries, non-obstructive CAD, moderate-to-severe CAD and CTO was 10 034 (44%), 7965 (34.9%), 4598 (20.1%) and 231 (1%), respectively. The mortality rate per 1000 person-years of CTO patients was non-significantly different from patients with moderate-to-severe CAD (22.95; 95% CI 12.71 to 41.45 vs 14.46; 95% CI 12.34 to 16.94; p=0.163), and significantly higher than of those with normal coronaries and non-obstructive CAD (p<0.001 for both). Among 14 382 individuals with follow-up for the composite end point, patients with CTO had a higher rate of events than those with moderate-to-severe CAD (106.56; 95% CI 76.51 to 148.42 vs 65.45; 95% CI 58.01 to 73.84, p=0.009). This difference was primarily driven by an increase in late revascularisations in CTO patients (27 of 35 events). After multivariable adjustment, compared with individuals with normal coronaries, the presence of CTO conferred the highest risk for adverse cardiac events (14.54; 95% CI 9.11 to 23.20, p<0.001).

Conclusions The detection of CTO on non-invasive CCTA is associated with increased rate of late revascularisation but similar 2-year mortality as compared with moderate-to-severe CAD.

Trial registration number NCT01443637.

  • cardiac computer tomographic (ct) imaging
  • heart disease

https://doi.org/10.1136/heartjnl-2017-312907

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    Footnotes

    • Contributors Drs MPO and FYL contributed to data analysis and interpretation as well as drafting, critical revision and final approval of the manuscript. Drs YL, SA, MHAl-M, DA, JJB, DSB, MJB, FC, TQC, H-JC, KC, BJWC, RCC, ADL, GMF, MH, JH, PAK, Y-JK, JAL, EM, HM, GP, GR, RR, LJS, TCV, MG, ECJ and JMP contributed to data acquisition and interpretation as well as critical revision and final approval of the manuscript. Dr HG contributed to data analysis as well as critical revision and final approval of the manuscript. Dr JKM contributed to planning, design, conduction and reporting of the work described in the article as well as critical revision and final approval of the manuscript. Dr JKM is responsible for the overall content as guarantor.

    • Funding The research reported in this publication was funded, in part, by the Heart, Lung and Blood Institute of the National Institutes of Health (Bethesda, Maryland, USA) under award number R01 HL115150, and also supported, in part, by the Dalio Institute of Cardiovascular Imaging (New York, New York, USA) and the Michael Wolk Heart Foundation (New York, New York, USA).

    • Competing interests Dr JKM receives funding from the Dalio Foundation, National Institutes of Health and GE Healthcare. Dr JKM serves on the scientific advisory board of Arineta and GE Healthcare, and has an equity interest in Cleerly. All other coauthors have no relevant disclosures.

    • Patient consent Obtained.

    • Ethics approval Weill Cornell Institutional Review Board.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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