1. Dr.Ravi PrakashModerator- Dr Roopa Salwan13-04-12

2. INTRODUCTIONCAC Scoring- in asymptomatic pt.CAD burdenCV risk prediction - in symptomatic pt. high sensitivity and ve predictive value to exclude CAD. 3. ACC/AHA GUIDELINECAC scoring (CACs) as a filter for coronary angiography in atypical ACS.CAC s > as binary testCAC+ve=further test considered.CAC ve=no further test required. 4. Recently question mark raised- in population of high pre test risk of CAD - incremental prognostic value of score -significant incidence of CAD in pt. having zero CACs. 5. AIM OF STUDYTo describe the prevalence and severity of CAD in relation to prognosis in - symptomatic patients -without known CAD - without coronary artery alcication - undergoing CCTA 6. METHODThe CONFIRM registry (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter)international, multicenter, observational registrycollecting clinical, procedural, and follow-up dataon patients who underwent 64-detector row CCTA between 2005 and 2009 at 12 centers in6 countries(Canada, Germany, Italy, Korea, Switzerland, and United States) 7. Symptomatic patients who underwent concomitantCAC scoring and CCTA were included.Individuals with known CAD were excluded. CAC s with Agatston method1130-199 HU 2 200-299 HU 3 300-399HU 4 >400HU 8. Lesion quantification LESION LUMINALCLINICAL GRADESTENOSIS SIGNIFICANCE NONE 0% MILD 1-49%NON OBSTRUCTIVE MODERA 50-69% OBSTRUCTIVE TE SEVERE > 70%SEVERELY OBSTRUCTIVE 9. FOLLOW UP AND OUTCOMEEND POINTS Primary- Death due to any causeSecondary- Consisting of-all-cause mortality, -nonfatal MI, and-coronary revascularizations done 90 days after CCTA. 10. RESULTS 27125 Patients screened10,037 Patients selected (symptomatic, without known CAD,undergoing CAC scoring and CCTA) 11. PROFILE OF STUDY GROUP Mean age =57 Male =56 % Among 10,037 pt. 51% has CAC score of 0.- young - female - low CV risk 12. Among CAC score=0 group 13% have non obstructive CAD 3.5% have obstructive CAD 1.4% have severe obstructive CAD 13. In group of obstructive CAD and CACs = 0 82% have SVD12% have DVD 6% have TVD 0.3% have LMD 14. For the detection of any stenosis> 50% on CCTA, thepresence of measurable CAC on calcium scoringdemonstrated a sensitivity of 89%, specicity of 59%,negative predictive value of 96%, and positivepredictive value of 29%. When using a threshold of 70% stenosis forobstructive CAD, a CAC score> 0 demonstrated asensitivity, specicity, negative predictive value andpositive predictive value of 92%, 55%, 99%, and 16%,respectively. 15. MORTALITY ADVERSE EFFECT 16. SURVIVAL WITH CACs=0 17. MACE stratified by CACs and stenosis 18. FOLLOW UP During a median follow-up of 2.1 years,patients with any obstructive CAD by CCTAexperienced a signicantly increased rate of all-causemortality . When restricted to individuals with a CAC score of 0,there was no difference in all-cause mortality despitethe presence of non obstructive or obstructive CAD 19. FOLLOW UP FOR SECONDARY ENDPOINT Among the 8,907 patients with complete follow-up for the secondary endpoints of coronary revascularization and MI, patients with evidence of obstructive CAD had significantly increased rates of early coronary revascularization, both among patients with and without coronary artery calcication. 20. COMPARATIVE PROGNOSTIC VALUE OF CLINICAL VARIABLES, CACSCORING AND CCTA. Independent predictor of adverse events Increasing CAC scores, The presence of nonobstructive CAD, Any stenosis >50%, and the number of coronary territories with 50% stenosis. 21. DISCUSSION Absence of calcification decreases the likelihood OfCAD ,but does not exclude it. Rate of obstructive CAD in person with zerocalcification varies between 7 38% Pt. with CACs=0 and obstructive CAD do not showincreased mortality due to predominent SVD. 22. LIMITATIONS OF STUDY1.Denition of CAD was made using CCTA, thepossibility of false-positive and false-negative CCTAndings exists.2. Patients diagnosed with obstructive CAD on CCTA aremore likely to undergo PCI/CABG, especially in earlydays.3. Differences in the application of medical therapiesafter CCTA were not assessed4.Individual plaque character was not studied. 23. CONCLUSION1.Absence of calcification decreases the likelihood OfCAD but does not exclude it. 2. Among patients without CAC, the presence of stenosis of > 50% is predictive of increased rates oflate coronary revascularizations and nonfatal MIsduring an intermediate-term follow-up period.3. CAC scoring performed at the time of CCTA does notappear to offer signicant incremental prognosticinformation 24. THANKS.