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Predictive Value of Age- and Sex-Specific Nomograms of Global Plaque Burden on Coronary Computed Tomography Angiography for Major Cardiac Events.

  • Author(s): Naoum, Christopher
  • Berman, Daniel S
  • Ahmadi, Amir
  • Blanke, Philipp
  • Gransar, Heidi
  • Narula, Jagat
  • Shaw, Leslee J
  • Kritharides, Leonard
  • Achenbach, Stephan
  • Al-Mallah, Mouaz H
  • Andreini, Daniele
  • Budoff, Matthew J
  • Cademartiri, Filippo
  • Callister, Tracy Q
  • Chang, Hyuk-Jae
  • Chinnaiyan, Kavitha
  • Chow, Benjamin
  • Cury, Ricardo C
  • DeLago, Augustin
  • Dunning, Allison
  • Feuchtner, Gudrun
  • Hadamitzky, Martin
  • Hausleiter, Joerg
  • Kaufmann, Philipp A
  • Kim, Yong-Jin
  • Maffei, Erica
  • Marquez, Hugo
  • Pontone, Gianluca
  • Raff, Gilbert
  • Rubinshtein, Ronen
  • Villines, Todd C
  • Min, James
  • Leipsic, Jonathon
  • et al.


Age-adjusted coronary artery disease (CAD) burden identified on coronary computed tomography angiography predicts major adverse cardiovascular event (MACE) risk; however, it seldom contributes to clinical decision making because of a lack of nomographic data. We aimed to develop clinically pragmatic age- and sex-specific nomograms of CAD burden using coronary computed tomography angiography and to validate their prognostic use.

Methods and results

Patients prospectively enrolled in phase I of the CONFIRM registry (Coronary CT Angiography Evaluation for Clinical Outcomes) were included (derivation cohort: n=21,132; 46% female) to develop CAD nomograms based on age-sex percentiles of segment involvement score (SIS) at each year of life (40-79 years). The relationship between SIS age-sex percentiles (SIS%) and MACE (all-cause death, myocardial infarction, unstable angina, and late revascularization) was tested in a nonoverlapping validation cohort (phase II, CONFIRM registry; n=3030, 44% female) by stratifying patients into 3 SIS% groups (≤50th, 51-75th, and >75th) and comparing annualized MACE rates and time to MACE using multivariable Cox proportional hazards models adjusting for Framingham risk and chest pain typicality. Age-sex percentiles were well fitted to second-order polynomial curves (men: R2=0.86±0.12; women: R2=0.86±0.14). Using the nomograms, there were 1576, 965, and 489 patients, respectively, in the ≤50th, 51-75th, and >75th SIS% groups. Annualized event rates were higher among patients with greater CAD burden (2.1% [95% confidence interval: 1.7%-2.7%], 3.9% [95% confidence interval: 3.0%-5.1%], and 7.2% [95% confidence interval: 5.4%-9.6%] in ≤50th, 51-75th, and >75th SIS% groups, respectively; P<0.001). Adjusted MACE risk was significantly increased among patients in SIS% groups above the median compared with patients below the median (hazard ratio [95% confidence interval]: 1.9 [1.3-2.8] for 51-75th SIS% group and 3.4 [2.3-5.0] for >75th SIS% group; P<0.01 for both).


We have developed clinically pragmatic age- and sex-specific nomograms of CAD prevalence using coronary computed tomography angiography findings. Global plaque burden measured using SIS% is predictive of cardiac events independent of traditional risk assessment.

Clinical trial registration

URL: Unique identifier: NCT01443637.

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