Incidental Coronary Artery Calcification Seen on Low-Dose Computed Tomography Is a Risk Factor for Obstructive Coronary Artery Disease in Patients Undergoing Liver Transplant

Preoperative non-invasive testing aims to provide informed choices about the appropriateness of surgery, guide perioperative management, and assess the long-term risk of a cardiac event through identification of left ventricular dysfunction, heart valve abnormalities, and myocardial ischaemia. Preoperative non-invasive testing is not recommended routinely, but it should be considered in patients in whom initial clinical evaluation indicates increased risk for perioperative cardiac complications and who are scheduled for intermediate- or high-risk surgery. Pharmacological stress testing combined with myocardial perfusion imaging or echocardiography is more suitable than physical exercise for the detection of myocardial ischaemia in patients with limited exercise tolerance that is common in the preoperative setting. Alternatively, non-invasive coronary computed tomography angiography can identify obstructive coronary artery disease. A negative stress testing with imaging or the absence of high-risk coronary anatomy on computed tomography angiography is associated with a low incidence of perioperative cardiac events, but the positive predictive value is relatively low, that is, the risk is relatively low despite a positive result. In patients with extensive stress-induced ischaemia or extensive obstructive coronary artery disease detected by non-invasive testing, individualized perioperative management is recommended considering the potential benefit of the proposed surgical procedure, weighed against the predicted risk of adverse outcome.

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Clinical risk factors and atherosclerotic plaque extent to define risk for major events in patients without obstructive coronary artery disease: the long-term coronary computed tomography angiography CONFIRM registry

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez322 ◽

2020 ◽

Vol 21 (5) ◽

pp. 479-488 ◽

Cited By ~ 3

Author(s):

Alexander R van Rosendael ◽

A Maxim Bax ◽

Jeff M Smit ◽

Inge J van den Hoogen ◽

Xiaoyue Ma ◽

...

Keyword(s):

Risk Factors ◽

Computed Tomography ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Computed Tomography Angiography ◽

Prognostic Value ◽

Coronary Computed Tomography Angiography ◽

Obstructive Coronary Artery Disease ◽

Artery Disease

Abstract Aims In patients without obstructive coronary artery disease (CAD), we examined the prognostic value of risk factors and atherosclerotic extent. Methods and results Patients from the long-term CONFIRM registry without prior CAD and without obstructive (≥50%) stenosis were included. Within the groups of normal coronary computed tomography angiography (CCTA) (N = 1849) and non-obstructive CAD (N = 1698), the prognostic value of traditional clinical risk factors and atherosclerotic extent (segment involvement score, SIS) was assessed with Cox models. Major adverse cardiac events (MACE) were defined as all-cause mortality, non-fatal myocardial infarction, or late revascularization. In total, 3547 patients were included (age 57.9 ± 12.1 years, 57.8% male), experiencing 460 MACE during 5.4 years of follow-up. Age, body mass index, hypertension, and diabetes were the clinical variables associated with increased MACE risk, but the magnitude of risk was higher for CCTA defined atherosclerotic extent; adjusted hazard ratio (HR) for SIS >5 was 3.4 (95% confidence interval [CI] 2.3–4.9) while HR for diabetes and hypertension were 1.7 (95% CI 1.3–2.2) and 1.4 (95% CI 1.1–1.7), respectively. Exclusion of revascularization as endpoint did not modify the results. In normal CCTA, presence of ≥1 traditional risk factors did not worsen prognosis (log-rank P = 0.248), while it did in non-obstructive CAD (log-rank P = 0.025). Adjusted for SIS, hypertension and diabetes predicted MACE risk in non-obstructive CAD, while diabetes did not increase risk in absence of CAD (P-interaction = 0.004). Conclusion Among patients without obstructive CAD, the extent of CAD provides more prognostic information for MACE than traditional cardiovascular risk factors. An interaction was observed between risk factors and CAD burden, suggesting synergistic effects of both.

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