Coronary Artery Calcium Scoring to Exclude Flow-Limiting Coronary Artery Disease in Symptomatic Stable Patients at Low or Intermediate Risk

Mouden, Mohamed; Timmer, Jorik R.; Reiffers, S.; Oostdijk, Ad H. J.; Knollema, Siert; Ottervanger, Jan Paul; Jager, Pieter L.

doi:10.1148/radiol.13122529

Cited by 50 publications

(29 citation statements)

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“…As patients with a CAC score of 0 demonstrated excellent prognosis independent of SPECT findings, the additional CAC score is likely to reduce the use of downstream invasive testing in this subset of patients. 22 After multivariate analysis, both CAC score and SPECT were independently associated with MACE. For patients with a CAC score ≥100, a stepwise increase of risk for events was present with higher CAC scores.…”

Section: Discussionmentioning

confidence: 98%

Prognostic Value of Coronary Artery Calcium Scoring in Addition to Single-Photon Emission Computed Tomographic Myocardial Perfusion Imaging in Symptomatic Patients

Engbers

Timmer

Ottervanger

et al. 2016

Circ: Cardiovascular Imaging

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Background— The prognostic value of coronary artery calcium (CAC) scoring on top of myocardial perfusion imaging with single-photon emission computed tomography (SPECT) in patients suspected for coronary artery disease is not well established. Methods and Results— Four thousand eight hundred ninety-seven symptomatic patients without a history of coronary artery disease referred for SPECT and CAC scoring were included. Major adverse cardiac events (MACEs) were defined as late revascularization (>90 days after scanning), nonfatal myocardial infarction, and all-cause mortality. The frequency of abnormal SPECT increased with higher CAC scores, from 12% in patients with CAC scores of 0 to 19%, 32%, 37%, and 50% among those with CAC scores 1 to 99, 100 to 399, 400 to 999, and ≥1000, respectively ( P <0.001). During a median follow-up of 940 days (25th to 75th percentile, 581–1377), a total of 278 MACEs were observed. Overall incidence of MACE was 2.3% per year. A stepwise increase of MACE was present with increasing CAC scores, both in patients with normal SPECT (annual event rate CAC score 0: 0.6%; CAC score ≥1000: 5.5%) and abnormal SPECT (annual event rate CAC score 0: 0.4%; CAC score ≥1000: 7.6%). After multivariate analysis, both SPECT and CAC score were independent predictors of MACE (CAC score ≥1000: hazard ratio, 7.7; P <0.001 and large perfusion defect on SPECT: hazard ratio, 3.7; P <0.001). Conclusions— CAC score and SPECT are independent predictors of MACE in patients suspected for coronary artery disease. Our findings strongly support performing a CAC score in addition to SPECT in symptomatic patients to better define the risk of events during follow-up.

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Section: Discussionmentioning

confidence: 98%

Prognostic Value of Coronary Artery Calcium Scoring in Addition to Single-Photon Emission Computed Tomographic Myocardial Perfusion Imaging in Symptomatic Patients

Engbers

Timmer

Ottervanger

et al. 2016

Circ: Cardiovascular Imaging

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“…8 According to the most recent American Heart Association (AHA) 9 and American College of Cardiology Foundation (ACCF)/AHA 10 guidelines, CAC has Class IIA and IIB recommendations for assessing risk in intermediate and low-to-intermediate asymptomatic patients, respectively, and in guiding management of hyperlipidemia. 11 Studies also indicate that CAC may accurately risk stratify both low risk stable patients with new onset chest pain 12,13 and those presenting to the emergency department with acute chest pain, and has a Class IIB recommendation for use in symptomatic individuals. 9,14 It should be noted that CAC does not test for obstructive disease or functional ischemia, but rather is a surrogate for coronary atherosclerotic plaque burden.…”

Section: Introductionmentioning

confidence: 99%

Prognostic Value of Coronary Artery Calcium in the PROMISE Study (Prospective Multicenter Imaging Study for Evaluation of Chest Pain)

et al. 2017

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Background Coronary artery calcium (CAC) is an established predictor of future major adverse atherosclerotic cardiovascular events in asymptomatic individuals. However limited data exist as to how CAC compares to functional testing (FT) in estimating prognosis in symptomatic patients. Methods In the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial, patients with stable chest pain (or dyspnea) and intermediate pre-test probability for obstructive coronary artery disease (CAD) were randomized to FT (exercise electrocardiography, nuclear stress, or stress echocardiography) or anatomic testing. We evaluated those who underwent CAC testing as part of the anatomic evaluation (n=4,209) and compared to results of FT (n=4,602). We stratified CAC and FT results as normal or mildly, moderately or severely abnormal (for CAC: 0, 1–99 Agatston Score [AS], 100–400 AS and >400 AS, respectively; for FT: normal, mild=late positive treadmill, moderate=early positive treadmill or single-vessel ischemia and severe=large ischemic region abnormality). The primary endpoint was all-cause death, myocardial infarction or unstable angina hospitalization over a median follow-up of 26.1 months. Cox regression models were used to calculate hazard ratios and C-statistic to determine predictive and discriminatory value. Results Overall, the distribution of normal or mildly, moderately or severely abnormal test results was significantly different between FT and CAC (FT = normal 3588 [78.0%], mild 432 [9.4%], moderate 217 [4.7%], severe 365 [7.9%]; CAC = normal 1,457 [34.6%], mild 1340 [31.8%], moderate 772 [18.3%], severe 640 [15.2%], p <0.0001). Moderate and severe abnormalities in both arms robustly predicted events (moderate: CAC HR 3.14, 95% CI 1.81–5.44 and FT HR 2.65, 95% CI 1.46–4.83; severe: CAC HR 3.56, 95% CI 1.99–6.36 and FT HR 3.88, 95% CI 2.58–5.85. In the CAC arm, the majority of events (n=112/133; 84%) occurred in patients with any positive CAC test (score >0) whereas less than half of events occurred in patients with mild, moderate or severely abnormal FT (n=57/132; 43%) (p<0.001). In contrast, any abnormality on FT was significantly more specific for predicting events (78.6% for FT vs 35.2% for CAC, p<0.001). Overall discriminatory ability in predicting the primary endpoint of mortality, nonfatal myocardial infarction, and unstable angina hospitalization was similar and fair for both CAC and FT (c-statistic, 0.67 vs. 0.64). Coronary computed tomographic angiography provided significantly better prognostic information compared to FT and CAC testing (C-index: 0.72). Conclusion Among stable outpatients presenting with suspected CAD, most patients experiencing clinical events have measurable CAC at baseline while less than half have any abnormalities on FT. However, an abnormal FT was more specific for cardiovascular events, leading to overall similarly modest discriminatory abilities of both tests. Clinical Trial Registration URL: https://clinicaltrials.gov; Unique Identifier: NCT01174550

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“…NICE guidelines currently recommend CT calcium scoring when in patients with a low (10%–29%) likelihood of CAD. There is emerging evidence that extending CT calcium scoring to patients with low and intermediate pretest probability of CAD, in addition to (but not in place of) clinical assessment could also improve CAD prediction 8 25 26. The availability of this test to RACPC clinicians, although increasing, is still variable.…”

Section: Discussionmentioning

confidence: 99%

Clinical outcomes when applying NICE guidance for the investigation of recent-onset chest pain to a rapid-access chest pain clinic population

Patterson

Nair

Ahmed

et al. 2014

Heart

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Coronary Artery Calcium Scoring to Exclude Flow-Limiting Coronary Artery Disease in Symptomatic Stable Patients at Low or Intermediate Risk

Abstract: A CAC score of zero in stable patients at low or intermediate risk excludes flow-limiting CAD. These findings support the possibility of CAC scoring as a simple and safe tool to select patients for additional testing or discharge, as recommended in the literature.

Cited by 50 publications

References 36 publications

Prognostic Value of Coronary Artery Calcium Scoring in Addition to Single-Photon Emission Computed Tomographic Myocardial Perfusion Imaging in Symptomatic Patients

Prognostic Value of Coronary Artery Calcium Scoring in Addition to Single-Photon Emission Computed Tomographic Myocardial Perfusion Imaging in Symptomatic Patients

Prognostic Value of Coronary Artery Calcium in the PROMISE Study (Prospective Multicenter Imaging Study for Evaluation of Chest Pain)

Clinical outcomes when applying NICE guidance for the investigation of recent-onset chest pain to a rapid-access chest pain clinic population

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