Prognostic Impact of CCTA According to Standard Cardiovascular Modifiable Risk Factors.

BACKGROUND: The prognostic value of coronary computed tomographic angiography (CCTA) findings across standard modifiable risk factor (SMuRF) categories has not been explored. OBJECTIVES: We evaluated whether SMuRF burden modifies the prognostic value of the different coronary artery disease (CAD) categories on CCTA. METHODS: Patients without prior CAD who underwent clinically indicated CCTA were included. CCTA findings were categorized as absent CAD (0% stenosis), nonobstructive CAD (1% to 49%), or obstructive CAD (≥50%). SMuRF burden was defined by hypertension, dyslipidemia, diabetes, and smoking, and classified from 0 to 4. The primary endpoint was all-cause mortality or myocardial infarction (MI). RESULTS: Among 29,840 patients (mean age 64 ± 14 years, 53% men), 33% had absent CAD, 43% nonobstructive CAD, and 23% obstructive CAD. Over a median follow-up of 2 years, 2,030 patients (7%) experienced death or MI. Across all CAD categories, higher SMuRF burden was associated with higher cumulative incidence of death or MI rates and higher incidence rates (P < 0.001). Incidence rates per 1,000 person-years across SMuRF categories 0 to 4 increased from 10 to 74 in absent CAD, and 35 to 75 in obstructive CAD (P < 0.001). In adjusted models, each 1-SMuRF increase was associated with a higher risk across all CAD groups (HR: 1.41; 95% CI: 1.27-1.56 for absent CAD; HR: 1.26; 95% CI: 1.17-1.35 for nonobstructive CAD; HR: 1.29; 95% CI: 1.19-1.40 for obstructive CAD). Adding SMuRF burden to age, sex, body mass index, and CAD severity significantly improved prognostic discrimination (C-index 0.653-0.673; P < 0.001). CONCLUSIONS: Across CCTA-defined stenosis categories, SMuRF burden provides incremental prognostic information beyond anatomic disease severity, supporting its integration into CCTA-based risk stratification and personalized preventive management.