Prognostic Value of Coronary CTA in Stable Chest Pain CAD-RADS, CAC, and Cardiovascular Events in PROMISE

OBJECTIVES The purpose of this study was to compare Coronary Artery Disease Reporting and Data System (CAD- RADS) to traditional stenosis categories and the coronary artery calcium score (CACS) for predicting cardiovascular events in patients with stable chest pain and suspected coronary artery disease (CAD). BACKGROUND The 2016 CAD-RADS has been established to standardize the reporting of CAD on coronary CT angi- ography (CTA). METHODS PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial participants ' CTAs were assessed by a central CT core laboratory for CACS, traditional stenosis-based categories, and modi fied CAD-RADS grade including high -risk coronary plaque (HRP) features. Traditional stenosis categories and CAD-RADS grade were compared for the prediction of the composite endpoint of death, myocardial infarction, or hospitalization for unstable angina over a median follow-up of 25 months. Incremental prognostic value over traditional risk factors and CACS was assessed. RESULTS In 3,840 eligible patients (mean age: 60.4 +/- 8.2 years; 49% men), 3.0% (115) experienced events. CAD-RADS (concordance statistic [C -statistic] 0.747) had signi ficantly higher discriminatory value than traditional stenosis-based assessments (C -statistic 0.698 to 0.717; all p for comparison #0.001). With no plaque (CAD-RADS 0) as the baseline, the hazard ratio (HR) for an event increased from 2.43 (95% con fidence interval [CI]: 1.16 to 5.08) for CAD-RADS 1 to 21.84 (95% CI: 8.63 to 55.26) for CAD-RADS 4b and 5. In stepwise nested models, CAD-RADS added incremental prognostic value beyond ASCVD risk score and CACS (C -statistic 0.776 vs. 0.682; p < 0.001), and added incremental value persisted in all CACS strata. CONCLUSIONS These data from a large representative contemporary cohort of patients undergoing coronary CTA for stable chest pain support the prognostic value of CAD-RADS as a standard reporting system for coronary CTA.