Document Detail

All-cause mortality benefit of coronary revascularization vs. medical therapy in patients without known coronary artery disease undergoing coronary computed tomographic angiography: results from CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry).
MedLine Citation:
PMID:  23048194     Owner:  NLM     Status:  MEDLINE    
AIMS: To date, the therapeutic benefit of revascularization vs. medical therapy for stable individuals undergoing invasive coronary angiography (ICA) based upon coronary computed tomographic angiography (CCTA) findings has not been examined.
METHODS AND RESULTS: We examined 15 223 patients without known coronary artery disease (CAD) undergoing CCTA from eight sites and six countries who were followed for median 2.1 years (interquartile range 1.4-3.3 years) for an endpoint of all-cause mortality. Obstructive CAD by CCTA was defined as a ≥50% luminal diameter stenosis in a major coronary artery. Patients were categorized as having high-risk CAD vs. non-high-risk CAD, with the former including patients with at least obstructive two-vessel CAD with proximal left anterior descending artery involvement, three-vessel CAD, and left main CAD. Death occurred in 185 (1.2%) patients. Patients were categorized into two treatment groups: revascularization (n = 1103; 2.2% mortality) and medical therapy (n = 14 120, 1.1% mortality). To account for non-randomized referral to revascularization, we created a propensity score developed by logistic regression to identify variables that influenced the decision to refer to revascularization. Within this model (C index 0.92, χ2 = 1248, P < 0.0001), obstructive CAD was the most influential factor for referral, followed by an interaction of obstructive CAD with pre-test likelihood of CAD (P = 0.0344). Within CCTA CAD groups, rates of revascularization increased from 3.8% for non-high-risk CAD to 51.2% high-risk CAD. In multivariable models, when compared with medical therapy, revascularization was associated with a survival advantage for patients with high-risk CAD [hazards ratio (HR) 0.38, 95% confidence interval 0.18-0.83], with no difference in survival for patients with non-high-risk CAD (HR 3.24, 95% CI 0.76-13.89) (P-value for interaction = 0.03).
CONCLUSION: In an intermediate-term follow-up, coronary revascularization is associated with a survival benefit in patients with high-risk CAD by CCTA, with no apparent benefit of revascularization in patients with lesser forms of CAD.
James K Min; Daniel S Berman; Allison Dunning; Stephan Achenbach; Mouaz Al-Mallah; Matthew J Budoff; Filippo Cademartiri; Tracy Q Callister; Hyuk-Jae Chang; Victor Cheng; Kavitha Chinnaiyan; Benjamin J W Chow; Ricardo Cury; Augustin Delago; Gudrun Feuchtner; Martin Hadamitzky; Joerg Hausleiter; Philipp Kaufmann; Ronald P Karlsberg; Yong-Jin Kim; Jonathon Leipsic; Fay Y Lin; Erica Maffei; Fabian Plank; Gilbert Raff; Todd Villines; Troy M Labounty; Leslee J Shaw
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Publication Detail:
Type:  Comparative Study; Evaluation Studies; Journal Article; Multicenter Study; Research Support, Non-U.S. Gov't     Date:  2012-10-09
Journal Detail:
Title:  European heart journal     Volume:  33     ISSN:  1522-9645     ISO Abbreviation:  Eur. Heart J.     Publication Date:  2012 Dec 
Date Detail:
Created Date:  2012-12-17     Completed Date:  2013-05-20     Revised Date:  2013-12-04    
Medline Journal Info:
Nlm Unique ID:  8006263     Medline TA:  Eur Heart J     Country:  England    
Other Details:
Languages:  eng     Pagination:  3088-97     Citation Subset:  IM    
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MeSH Terms
Aged, 80 and over
Cardiotonic Agents / therapeutic use*
Coronary Angiography / methods,  mortality
Coronary Artery Bypass / statistics & numerical data
Coronary Artery Disease / mortality,  radiography
Coronary Stenosis / mortality,  radiography,  therapy*
Middle Aged
Myocardial Revascularization / mortality*
Percutaneous Coronary Intervention / statistics & numerical data
Propensity Score
Prospective Studies
Tomography, X-Ray Computed / methods,  mortality
Young Adult
Grant Support
Reg. No./Substance:
0/Cardiotonic Agents
Comment In:
Eur Heart J. 2012 Dec;33(24):3011-3   [PMID:  23117163 ]

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