Incremental prognostic value of coronary CTA after treadmill testing in noncardiac surgery candidates: Results from a multicenter prospective cohort

초록

Background: Preoperative cardiac risk assessment is critical in patients undergoing intermediate-to high-risk non-cardiac surgery. While both treadmill testing (TMT) and coronary computed tomography angiography (CTA) are widely used, the incremental prognostic value of combining these modalities remains unclear. Objectives: To evaluate the additive predictive value of coronary CTA when performed after TMT in patients scheduled for non-cardiac surgery. Methods: In this prospective multicenter cohort study conducted at two tertiary hospitals (Changwon Gyeongsang National University Hospital and Gyeongsang National University Hospital), 447 patients undergoing non-cardiac surgery were enrolled between January 2018 and April 2025. All patients underwent both TMT and coronary CTA prior to surgery. The primary endpoint was 30-day major adverse cardiac events (MACE), defined as a composite of cardiac death, nonfatal myocardial infarction, myocardial injury after noncardiac surgery, pulmonary edema with heart failure, clinically significant arrhythmias requiring urgent intervention, and prophylactic coronary revascularization. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC), and incremental prognostic value was evaluated using net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Results: Forty-five patients (10.1%) experienced MACE. Significant coronary stenosis (>= 50%) and a high coronary artery calcium score (CACS >= 203) on CTA were strong independent predictors of perioperative events. Among patients with positive TMT results, the addition of CTA significantly improved risk prediction. Importantly, even among TMT-negative patients, CTA findings provided meaningful discriminatory value. Conversely, TMT contributed modest incremental prognostic information in patients with significant coronary stenosis identified on CTA. Overall, models integrating both anatomic and functional assessments demonstrated the best predictive performance. Conclusions: Coronary CTA provides incremental prognostic value beyond TMT for predicting 30-day perioperative MACE in patients undergoing non-cardiac surgery. A combined strategy incorporating both anatomic and functional testing may enhance perioperative risk stratification and support more informed clinical decision-making.

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