Prognostic Value of AI-Based Quantitative Coronary CTA vs Human Reader-Based Visual Assessment
JACC. Cardiovascular imaging, vol. 19, pp. 345–359
Abstract
BACKGROUND: The severity and extent of whole heart coronary plaque volume and stenosis can be reliably measured by artificial intelligence-guided quantitative coronary computed tomography angiography (AI-QCT). Limited data are available on the potential incremental prognostic value compared with currently recommended qualitative coronary computed tomography angiography (CTA) reads and the coronary artery calcium score (CACS). OBJECTIVES: The aim of this study was to evaluate the prognostic value of AI-QCT compared with human coronary CTA reads, including the CAD-RADS (Coronary Artery Disease-Reporting and Data System), CACS, and the modified Duke Index. METHODS: CONFIRM2 (Quantitative COroNary CT Angiography Evaluation For Evaluation of Clinical Outcomes: An InteRnational, Multicenter Registry) is a multicenter, international, observational cohort study of patients undergoing clinically indicated coronary CTA with follow-up for major adverse cardiac events (MACE). Asymptomatic patients and those with cardiac history were excluded. Coronary artery disease presence, extent, and composition were quantified by AI-QCT across the coronary tree, yielding 24 patient-, vessel-, and plaque-level variables. On the basis of prior analyses, noncalcified plaque burden and diameter stenosis were identified as the strongest predictors and combined for statistical modeling as "AI-QCT." Comparator computed tomography scores included CAD-RADS, CACS, and the modified Duke Index, whereas clinical predictors were summarized in the risk factor-weighted clinical likelihood score. Area under the curve (AUC) and continuous net reclassification index (NRI) were calculated to assess the incremental value. The primary endpoint was MACE (death, myocardial infarction [MI], stroke, heart failure, late revascularization, or hospital stay for unstable angina), and the secondary endpoint was death or MI. RESULTS: In 1,916 patients with all risk scores available, 87 (4.5%) MACE and 27 (1.4%) death/MI events occurred during 3 years of follow-up. There was a stepwise risk increase with higher coronary artery disease classifications with CAD-RADS and CACS. The addition of AI-QCT significantly improved risk stratification for MACE compared with CAD-RADS (AUC: 0.81 vs 0.79; P < 0.001 and NRI: 0.47; P < 0.001), CACS (AUC: 0.79 vs 0.70; P < 0.001 and NRI 0.61; P < 0.001), the modified Duke Index (AUC: 0.81 vs 0.76; P < 0.001 and NRI: 0.52; P < 0.001), and CAD-RADS + CACS model (AUC: 0.81 vs 0.79; P = 0.004 and NRI: 0.54; P < 0.001). AI-QCT also improved discrimination when results were adjusted for the risk factor-weighted clinical likelihood and for the prediction of death/MI. Excluding 195 patients with severe stenosis (≥70%), in a multivariable model of CAD-RADS and AI-QCT, only AI-QCT was significantly associated with MACE and death/MI, and AI-QCT significantly improved risk stratification compared with CAD-RADS for MACE (AUC: 0.77 vs 0.72; P < 0.001 and NRI: 0.54; P < 0.001) and death/MI (AUC: 0.81 vs 0.73; P = 0.011 and NRI: 0.69; P = 0.001). CONCLUSIONS: AI-QCT provided incremental prognostic information compared with CAD-RADS 2.0, CACS, and the modified Duke Index for the prediction of MACE as well as the secondary endpoint of death or nonfatal MI.
Authors 55
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Leiden University Medical Center
Affiliation as printed
Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
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Department of Cardiovascular Medicine, Toho University Graduate School of Medicine, Tokyo, Japan
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Leiden University Medical Center
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Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
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University of Milan · Centro Cardiologico Monzino
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Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
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University of Zurich · University Hospital Zurich
Affiliation as printed
Department of Nuclear Medicine, Cardiac Imaging, University Hospital and University of Zurich, Zurich, Switzerland
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University of Bern · University Hospital of Bern
Affiliation as printed
Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Innsbruck Medical University · Universität Innsbruck
Affiliation as printed
Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
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Innsbruck Medical University · Universität Innsbruck
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Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
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Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia, USA
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Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia, USA
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Affiliation as printed
Department of Cardiology and Radiology, George Washington University, Washington, District of Columbia, USA
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Affiliation as printed
Department of Cardiology, Houston Methodist, Houston, Texas, USA
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University of Milan · IRCCS Ospedale Galeazzi - Sant'Ambrogio
Affiliation as printed
Division of University Cardiology, IRCCS Galeazzi Sant'Ambrogio, Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
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Cedars-Sinai Medical Center · University of California, Los Angeles · Cedars-Sinai Smidt Heart Institute
Affiliation as printed
Cardiovascular Research Foundation of Southern California, Beverly Hills, California, USA; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Cedars-Sinai Medical Center · University of California, Los Angeles · Cedars-Sinai Smidt Heart Institute
Affiliation as printed
Cardiovascular Research Foundation of Southern California, Beverly Hills, California, USA; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
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Universidade de São Paulo · Instituto do Coração - HCFMUSP
Affiliation as printed
Heart Institute, InCor, University of Sao Paulo Medical School, Sao Paulo, Brazil
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King Fahd Armed Forces Hospital
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Cardiac Center, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
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Tel Aviv University · Rabin Medical Center
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Department of Cardiology, Rabin Medical Center, Petah Tikva & Tel-Aviv University, Tel-Aviv, Israel
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Istituto di Ricovero e Cura a Carattere Scientifico SYNLAB Servizi Diagnostici Nucleari, Naples, Italy
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Department of Radiology, Istituto di Ricerca e Cura a Carattere Scientifico SYNLAB SDN, Naples, Italy
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Affiliation as printed
UNICA, Unit of Cardiovascular Imaging, Hospital da Luz, Imaging Department, Católica Medical School, Lisbon, Portugal
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Affiliation as printed
UNICA, Unit of Cardiovascular Imaging, Hospital da Luz, Imaging Department, Católica Medical School, Lisbon, Portugal
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Affiliation as printed
Cardiac Imaging, Heart and Vascular Institute, Valley Health System, Paramus, New Jersey, USA
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Deutsches Herzzentrum München · Technical University of Munich
Affiliation as printed
Department of Cardiovascular Radiology and Nuclear Medicine, TUM University Hospital German Heart Center, Munich, Germany
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Division of Cardiovascular Imaging, St. Francis Hospital and Heart Center, Roslyn, New York, USA
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Affiliation as printed
Division of Cardiology, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Amsterdam University Medical Centers · Vrije Universiteit Amsterdam · University of Amsterdam
Affiliation as printed
Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Amsterdam University Medical Centers · Vrije Universiteit Amsterdam · Amsterdam UMC Location Vrije Universiteit Amsterdam
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Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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The Lundquist Institute, Torrance, California, USA
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University of Tennessee Medical Center
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University of Tennessee Medical Center, Knoxville, Tennessee, USA
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Oregon Health & Science University
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Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
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Oregon Health & Science University
Affiliation as printed
Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
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Affiliation as printed
Allegheny Health Network Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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University of Wisconsin–Madison
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Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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University of Wisconsin–Madison
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Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, USA
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Affiliation as printed
Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, USA
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Aristotle University of Thessaloniki
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1st Cardiology Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Harvard University · Massachusetts General Hospital
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Department of Radiology, Cardiovascular Imaging and Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Harvard University · Massachusetts General Hospital
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Department of Radiology, Cardiovascular Imaging and Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Minneapolis Heart Institute, Minneapolis, Minnesota, USA
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Division of Cardiology, University of Washington, Seattle, Washington, USA
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University of Pittsburgh Medical Center
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Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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National Institute of Cardiovascular Diseases
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National Institute of Cardiovascular Diseases, Karachi, Pakistan
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Piedmont Heart Institute, Atlanta, Georgia, USA
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Department of Cardiovascular Computed Tomography, Scripps Clinic, La Jolla, California, USA
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Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Affiliation as printed
Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Mount Auburn Hospital · Harvard University
Affiliation as printed
Medical Data Research Collaborative, London, United Kingdom; Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
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Affiliation as printed
Cardiology, Endeavor NorthShore Cardiovascular Institute, Evanston, Illinois, USA; University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
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Department of Cardiac Imaging, Baylor Scott and White, The Heart Hospital Plano, Plano, Texas, USA
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Midwest Heart & Vascular Associates, Kansas City, Missouri, USA
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Radboud University Nijmegen · Radboud University Medical Center
Affiliation as printed
Cleerly, Inc, Denver, Colorado, USA; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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Affiliation as printed
Cleerly, Inc, Denver, Colorado, USA
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Ibrahim Danad corresponding
Radboud University Nijmegen · Radboud University Medical Center
Affiliation as printed
Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands. Electronic address: Ibrahim.Danad@Radboudumc.nl
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