Korean J Radiol.  2020 Sep;21(9):1055-1064. 10.3348/kjr.2020.0103.

Prognostic Value of Coronary CT Angiography forPredicting Poor Cardiac Outcome in Stroke Patientswithout Known Cardiac Disease or Chest Pain:The Assessment of Coronary Artery Disease in StrokePatients Study

  • 1Departments of 1Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
  • 2Department of Radiology, Ewha Womans University Mokdong Hospital, Seoul, Korea
  • 3Department of Applied Statistics, College of Business and Economics, Yonsei University, Seoul, Korea
  • 4Departments of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
  • 5Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
  • 6Department of Internal Medicine, Samsung Medical Center, Seoul, Korea
  • 7Department of Radiology, CHA University Bundang Medical Center, Seongnam, Korea
  • 8Department of Radiology, University of Maryland, Baltimore, MD, USA


To assess the incremental prognostic value of coronary computed tomography angiography (CCTA) in comparison toa clinical risk model (Framingham risk score, FRS) and coronary artery calcium score (CACS) for future cardiac events in ischemicstroke patients without chest pain.
Materials and Methods
This retrospective study included 1418 patients with acute stroke who had no previous cardiac diseaseand underwent CCTA, including CACS. Stenosis degree and plaque types (high-risk, non-calcified, mixed, or calcified plaques) wereassessed as CCTA variables. High-risk plaque was defined when at least two of the following characteristics were observed:low-density plaque, positive remodeling, spotty calcification, or napkin-ring sign. We compared the incremental prognosticvalue of CCTA for major adverse cardiovascular events (MACE) over CACS and FRS.
The prevalence of any plaque and obstructive coronary artery disease (CAD) (stenosis ≥ 50%) were 70.7% and 30.2%,respectively. During the median follow-up period of 48 months, 108 patients (7.6%) experienced MACE. Increasing FRS, CACS,and stenosis degree were positively associated with MACE (all p< 0.05). Patients with high-risk plaque type showed the highestincidence of MACE, followed by non-calcified, mixed, and calcified plaque, respectively (log-rank p< 0.001). Among theprediction models for MACE, adding stenosis degree to FRS showed better discrimination and risk reclassification compared toFRS or the FRS + CACS model (all p< 0.05). Furthermore, incorporating plaque type in the prediction model significantly improvedreclassification (integrated discrimination improvement, 0.08; p= 0.023) and showed the highest discrimination index(C-statistics, 0.85). However, the addition of CACS on CCTA with FRS did not add to the prediction ability for MACE (p> 0.05).
Assessment of stenosis degree and plaque type using CCTA provided additional prognostic value over CACS andFRS to risk stratify stroke patients without prior history of CAD better.


Coronary computed tomography angiography; Coronary artery calcium scoring; Stroke; Plaque, atherosclerotic; Coronary stenosis
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