Superior Risk Stratification With Coronary Computed Tomography Angiography Using a Comprehensive Atherosclerotic Risk Score

Alexander R. van Rosendael, Leslee J. Shaw, Joe X. Xie, Aukelien C. Dimitriu-Leen, Jeff M. Smit, Arthur J. Scholte, Jacob M. van Werkhoven, Tracy Q. Callister, Augustin DeLago, Daniel S. Berman, Martin Hadamitzky, Jeorg Hausleiter, Mouaz H. Al-Mallah, Matthew J. Budoff, Philipp A. Kaufmann, Gilbert Raff, Kavitha Chinnaiyan, Filippo Cademartiri, Erica Maffei, Todd C. VillinesYong Jin Kim, Gudrun Feuchtner, Fay Y. Lin, Erica C. Jones, Gianluca Pontone, Daniele Andreini, Hugo Marques, Ronen Rubinshtein, Stephan Achenbach, Allison Dunning, Millie Gomez, Niree Hindoyan, Heidi Gransar, Jonathon Leipsic, Jagat Narula, James K. Min, Jeroen J. Bax

Research output: Contribution to journalArticlepeer-review

83 Scopus citations


Objectives: This study was designed to assess the prognostic value of a new comprehensive coronary computed tomography angiography (CTA) score compared with the stenosis severity component of the Coronary Artery Disease-Reporting and Data System (CAD-RADS). Background: Current risk assessment with coronary CTA is mainly focused on maximal stenosis severity. Integration of plaque extent, location, and composition in a comprehensive model may improve risk stratification. Methods: A total of 2,134 patients with suspected but without known CAD were included. The predictive value of the comprehensive CTA score (ranging from 0 to 42 and divided into 3 groups: 0 to 5, 6 to 20, and >20) was compared with the CAD-RADS combined into 3 groups (0% to 30%, 30% to 70% and ≥70% stenosis). Its predictive performance was internally and externally validated (using the 5-year follow-up dataset of the CONFIRM [Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry], n = 1,971). Results: The mean age of patients was 55 ± 13 years, mean follow-up 3.6 ± 2.8 years, and 130 events (myocardial infarction or death) occurred. The new, comprehensive CTA score showed strong and independent predictive value using the Cox proportional hazard analysis. A model including clinical variables plus comprehensive CTA score showed better discrimination of events compared with a model consisting of clinical variables plus CAD-RADS (0.768 vs. 0.742, p = 0.001). Also, the comprehensive CTA score correctly reclassified a significant proportion of patients compared with the CAD-RADS (net reclassification improvement 12.4%, p < 0.001). Good predictive accuracy was reproduced in the external validation cohort. Conclusions: The new comprehensive CTA score provides better discrimination and reclassification of events compared with the CAD-RADS score based on stenosis severity only. The score retained similar prognostic accuracy when externally validated. Anatomic risk scores can be improved with the addition of extent, location, and compositional measures of atherosclerotic plaque. (Comprehensive CTA risk score calculator is available at:

Original languageEnglish (US)
Pages (from-to)1987-1997
Number of pages11
JournalJACC: Cardiovascular Imaging
Issue number10
StatePublished - Oct 2019


  • coronary computed tomography angiography
  • risk stratification
  • stable coronary artery disease

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine


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