Prognostic value of coronary electron-beam computed tomography for coronary heart disease events in asymptomatic populations1

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Abstract

The predictive ability of electron-beam computed tomography (EBCT) for coronary heart disease outcomes, particularly hard coronary outcomes (myocardial infarction or death), has been questioned in asymptomatic populations. Our objective was to synthesize data on the use of EBCT for determining cardiovascular prognosis in asymptomatic populations. Studies were identified using standard systematic review methods. The outcome of interest was relative risk for myocardial infarction or sudden death, and combined events including revascularization. Nine articles met the inclusion criteria, of which 5 were of independent studies. Using meta-analytic techniques to synthesize prognostic data, there was an increased risk (summary risk ratio 8.7, 95% confidence interval 2.7 to 28.1) of a combined outcome of nonfatal myocardial infarction or death or revascularization if the calcium score was above a median score. Similarly, there was an increased risk for hard events: myocardial infarction or death (summary risk ratio 4.2, 95% confidence interval 1.6 to 11.3). However, there was significant heterogeneity in the studies’ quality and patient populations. Although EBCT appears to predict combined and hard coronary outcomes similarly in high risk, asymptomatic populations, these results should be interpreted with caution. Further study is needed on the incremental value of EBCT over conventional risk prediction before this test is used in screening asymptomatic populations.

Section snippets

Data sources and study selection

We searched MEDLINE and EMBASE (1985 to September 1999) using the following text words and key words (all languages, limited to “human”): electron-beam computed tomography, ultrafast computed tomography, heart disease, and prognosis. We also searched the references of reviewed articles for additional articles missed by the computerized database search, and searched the National Institutes of Health Registry of unpublished and ongoing studies. Studies were screened for inclusion based on the

Results

Nine studies (4 full articles and 5 published abstracts) met the inclusion criteria3, 5, 13, 14 (unpublished data in abstract form; Hoff, Arad, Agatston, Callister, Sullivan). The data abstracted from each independent study are reported in Table I. Three reports included the study population of another, and so the more complete data were used for this summary. Because the follow-up of another study was only 33% and published in abstract form only, it was excluded from the synthesis.

Discussion

This synthesis of follow-up studies in middle to older aged, predominantly male, asymptomatic populations suggests a moderate to strong association between coronary calcification as detected by EBCT and hard and soft coronary outcomes. However, there are serious methodologic limitations to several of these studies, the most important of which is large losses to follow-up, a factor that could reasonably invalidate at least the strength of such an association.16

Important qualitative differences

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The views contained herein represent the private views of the authors and should not be construed in any way to represent those of the Department of Defense or the Department of the Army.

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