Coronary anatomy detects, ischemia predicts: Real-world insights from the Nancy ischemia registry.

Background: The respective roles of coronary atherosclerosis assessment and myocardial ischemia testing for cardiovascular risk stratification remain debated, particularly in real-world clinical practice where imaging strategies are guided by patient risk profile rather than random assignment. Methods: The Nancy Ischemia Registry prospectively included 3,020 consecutive patients between February 2021 and December 2022. Patients underwent either anatomical imaging [coronary artery calcium score (CACS) or coronary CT angiography (CCTA)] or functional ischemia testing [stress echocardiography or stress cardiovascular magnetic resonance (CMR)]. Follow-up was completed through December 2023. The primary endpoint was major adverse cardiovascular events (MACE), defined as cardiovascular death or myocardial revascularization. Results: Anatomical imaging was used almost exclusively in primary prevention, whereas ischemia-based testing included both primary and secondary prevention populations. Kaplan-Meier analysis showed a higher cumulative incidence of MACE among patients undergoing ischemia screening (20 %) compared with anatomical screening (15 %), with divergence after approximately 500 days. However, this difference was not confirmed after multivariable adjustment (HR 1.03, 95 % CI 0.87-1.23; p = 0.73), and residual confounding related to incomplete adjustment for cardiovascular risk factors cannot be excluded. Myocardial ischemia, particularly when associated with revascularization, was strongly associated with adverse events, while total atherosclerotic burden remained independently associated with outcomes. Age and male sex were additional predictors of MACE. Conclusions: In this real-world registry, anatomical imaging provided information on total atherosclerotic burden, whereas functional imaging identified patients with high-risk myocardial ischemia and subsequent revascularization. These findings offer real-world insights into the complementary roles of anatomical and functional imaging in distinct clinical populations and support an integrated, imaging-guided approach to personalized CAD management.