Long term prognostic utility of coronary CT angiography in patients with no modifiable coronary artery disease risk factors: Results from the 5 year follow-up of the CONFIRM International Multicenter Registry

•In patients without modifiable CAD risk factors, those without CAD by CCTA have a low rate of MACE and all cause mortality.•All cause mortality was predicted by >1 segment of non-obstructive CAD, obstructive 1&2 vessel and 3 vessel/left main CAD.•All-cause mortality demonstrated a dose-response relationship to the severity and number of coronary vessels with CAD.•Presence of non-obstructive and obstructive CAD predicted MACE.

BackgroundCoronary computed tomography angiography (coronary CTA) can prognosticate outcomes in patients without modifiable risk factors over medium term follow-up. This ability was driven by major adverse cardiovascular events (MACE).ObjectiveDetermine if coronary CTA could discriminate risk of mortality with longer term follow-up. In addition we sought to determine the long-term relationship to MACE.MethodsFrom 12 centers, 1884 patients undergoing coronary CTA without prior coronary artery disease (CAD) or any modifiable CAD risk factors were identified. The presence of CAD was classified as none (0% stenosis), mild (1% to 49% stenosis) and obstructive (≥50% stenosis severity). The primary endpoint was all-cause mortality and the secondary endpoint was MACE. MACE was defined as the combination of death, nonfatal myocardial infarction, unstable angina, and late target vessel revascularization (>90 days).ResultsMean age was 55.6 ± 14.5 years. At mean 5.6 ± 1.3 years follow-up, 145(7.7%) deaths occurred. All-cause mortality demonstrated a dose-response relationship to the severity and number of coronary vessels exhibiting CAD. Increased mortality was observed for >1 segment non-obstructive CAD (hazard ratio [HR]:1.73; 95% confidence interval [CI]: 1.07–2.79; p = 0.025), obstructive 1&2 vessel CAD (HR: 1.70; 95% CI: 1.08–2.71; p = 0.023) and 3-vessel or left main CAD (HR: 2.87; 95% CI: 1.57–5.23; p = 0.001). Both obstructive CAD (HR: 6.63; 95% CI: 3.91–11.26; p < 0.001) and non-obstructive CAD (HR: 2.20; 95% CI: 1.31–3.67; p = 0.003) predicted MACE with increased hazard associated with increasing CAD severity; 5.60% in no CAD, 13.24% in non-obstructive and 36.28% in obstructive CAD, p < 0.001 for trend.ConclusionsIn individuals being assessed for CAD with no modifiable risk factors, all-cause mortality in the long term (>5 years) was predicted by the presence of more than 1 segment of non-obstructive plaque, obstructive 1- or 2-vessel CAD and 3 vessel/left main CAD. Any CAD, whether non-obstructive or obstructive, predicted MACE over the same time period.