A zero coronary artery calcium score in patients with stable chest pain is associated with a good prognosis, despite risk of non-calcified plaques

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

Objectives

To estimate the prevalence of non-calcified coronary artery disease (CAD) in patients with suspected stable angina and a zero coronary artery calcification (CAC) score, and to assess the prognostic significance of a zero CAC in these symptomatic patients.

Methods

In this prospective cohort study, consecutive patients with stable chest pain underwent CAC scoring ± CT coronary angiography (CTCA) as part of routine clinical care at a single tertiary centre over 7 years. Major adverse cardiac event (MACE) was defined as cardiac death, non-fatal myocardial infarction and/or non-elective revascularisation.

Results

A total of 915 of 1753 (52.2%) patients (mean age 56.8 ± 12.0 years; 46.2% male) had a zero CAC score. Of the 751 (82.1%) patients with a zero CAC in whom CTCA was performed, 674 (89.7%) had normal coronary arteries, 63 (8.4%) had non-calcified CAD with < 50% stenosis and 14 (1.9%) had ≥ 50% stenosis in at least one coronary artery. The negative predictive value of a zero CAC for excluding a ≥ 50% CTCA stenosis was 98.1%. Over a median follow-up period of 2.2 years (range 1.0–7.0 years), the absolute annualised rates of MACE were as follows: zero CAC 1.9 per 1000 person-years and non-zero CAC 7.4 per 1000 person-years (HR 3.8, p = 0.009). However, after adjusting for age, gender and cardiovascular risk factors using a multivariable Cox proportional hazards model, there was no statistically significant difference in the risk of MACE between the two patient cohorts (p = 0.19). After adjusting for age, gender and cardiovascular risk factors, the HR for all-cause mortality among the zero CAC cohort vers non-zero CAC was 2.1 (p = 0.27).

Conclusion

A zero CAC score in patients undergoing CT scanning for suspected stable angina has a high negative predictive value for the exclusion of obstructive CAD and is associated with a good medium-term prognosis.

Related collections

Most cited references 13

Record: found
Abstract: found
Article: not found

Diagnostic and prognostic value of absence of coronary artery calcification.

Ammar Sarwar, Leslee J Shaw, Michael D Shapiro … (2009)

In this study, we systematically assessed the diagnostic and prognostic value of absence of coronary artery calcification (CAC) in asymptomatic and symptomatic individuals. Presence of CAC is a well-established marker of coronary plaque burden and is associated with a higher risk of adverse cardiovascular outcomes. Absence of CAC has been suggested to be associated with a very low risk of significant coronary artery disease, as well as minimal risk of future events. We searched online databases (e.g., PubMed and MEDLINE) for original research articles published in English between January 1990 and March 2008 examining the diagnostic and prognostic utility of CAC. A systematic review of published articles revealed 49 studies that fulfilled our criteria for inclusion. These included 13 studies assessing the relationship of CAC with adverse cardiovascular outcomes in 64,873 asymptomatic patients. In this cohort, 146 of 25,903 patients without CAC (0.56%) had a cardiovascular event during a mean follow-up period of 51 months. In the 7 studies assessing the prognostic value of CAC in a symptomatic population, 1.80% of patients without CAC had a cardiovascular event. Overall, 18 studies demonstrated that the presence of any CAC had a pooled sensitivity and negative predictive value of 98% and 93%, respectively, for detection of significant coronary artery disease on invasive coronary angiography. In 4,870 individuals undergoing myocardial perfusion and CAC testing, in the absence of CAC, only 6% demonstrated any sign of ischemia. Finally, 3 studies demonstrated that absence of CAC had a negative predictive value of 99% for ruling out acute coronary syndrome. On the basis of our review of more than 85,000 patients, we conclude that the absence of CAC is associated with a very low risk of future cardiovascular events, with modest incremental value of other diagnostic tests in this very low-risk group.

0 comments Cited 143 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Prevalence and severity of coronary artery disease and adverse events among symptomatic patients with coronary artery calcification scores of zero undergoing coronary computed tomography angiography: results from the CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) registry.

Todd Villines, Edward Hulten, Leslee J Shaw … (2011)

The purpose of this study was to describe the prevalence and severity of coronary artery disease (CAD) in relation to prognosis in symptomatic patients without coronary artery calcification (CAC) undergoing coronary computed tomography angiography (CCTA). The frequency and clinical relevance of CAD in patients without CAC are unclear. We identified 10,037 symptomatic patients without CAD who underwent concomitant CCTA and CAC scoring. CAD was assessed as 0 had a sensitivity, specificity, and negative and positive predictive values for stenosis ≥50% of 89%, 59%, 96%, and 29%, respectively. During a median of 2.1 years, there was no difference in mortality among patients with a CAC score of 0 irrespective of obstructive CAD. Among 8,907 patients with follow-up for the composite endpoint, 3.9% with a CAC score of 0 and ≥50% stenosis experienced an event (hazard ratio: 5.7; 95% confidence interval: 2.5 to 13.1; p < 0.001) compared with 0.8% of patients with a CAC score of 0 and no obstructive CAD. Receiver-operator characteristic curve analysis demonstrated that the CAC score did not add incremental prognostic information compared with CAD extent on CCTA for the composite endpoint (CCTA area under the curve = 0.825; CAC + CCTA area under the curve = 0.826; p = 0.84). In symptomatic patients with a CAC score of 0, obstructive CAD is possible and is associated with increased cardiovascular events. CAC scoring did not add incremental prognostic information to CCTA. Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

0 comments Cited 85 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: found

Is Open Access

The Updated NICE Guidelines: Cardiac CT as the First-Line Test for Coronary Artery Disease

Alastair J Moss, Michelle Williams, David Newby … (2017)

Purpose of Review Cost-effective care pathways are integral to delivering sustainable healthcare programmes. Due to the overestimation of coronary artery disease using traditional risk tables, non-invasive testing has been utilised to improve risk stratification and initiate appropriate management to reduce the dependence on invasive investigations. In line with recent technological improvements, cardiac CT is a modality that offers a detailed anatomical assessment of coronary artery disease comparable to invasive coronary angiography. Recent Findings The recent publication of the National Institute for Health and Care Excellences (NICE) Clinical Guideline 95 update assesses the performance and cost utility of different non-invasive imaging strategies in patients presenting with suspected anginal chest pain. The low cost and high sensitivity of cardiac CT makes it the non-invasive test of choice in the evaluation of stable angina. This has now been ratified in national guidelines with NICE recommending cardiac CT as the first-line investigation for all patients presenting with chest pain due to suspected coronary artery disease. Additionally, randomised controlled trials have demonstrated that cardiac CT improves diagnostic certainty when incorporated into chest pain pathways. Summary NICE recommend cardiac CT as the first-line test for the evaluation of stable coronary artery disease in chest pain pathways.

0 comments Cited 84 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Journal

Journal ID (nlm-ta): Open Heart

Journal ID (iso-abbrev): Open Heart

Journal ID (hwp): openhrt

Journal ID (publisher-id): openheart

Title: Open Heart

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2053-3624

Publication date Collection: 2019

Publication date (Electronic): 11 April 2019

Volume: 6

Issue: 1

Electronic Location Identifier: e000945

Affiliations

[1 ]Division of Cardiovascular Medicine, University of Cambridge, Addenbrooke's Hospital , Cambridge, UK

[2 ]Department of Clinical Radiology, Imperial College Hospitals NHS Trust, St Mary's Hospital , London, UK

[3 ]Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital , Cambridge, UK

[4 ]Department of Radiology, Addenbrooke's Hospital , Cambridge, UK

[5 ]departmentCentre for Cardiovascular Sciences , University of Edinburgh , Edinburgh, UK

Author notes

[Correspondence to ] Dr James H F Rudd, Division of Cardiovascular Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK; jhfr2@ 123456cam.ac.uk

Author information

Elizabeth Phuong Vi Le http://orcid.org/0000-0002-3065-1627

Article

Publisher ID: openhrt-2018-000945

DOI: 10.1136/openhrt-2018-000945

PMC ID: 6519430

PubMed ID: 31168373

SO-VID: 5d7dd658-200b-46b5-a5fa-5bd61684b250

License:

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

History

Date received : 09 October 2018

Date revision received : 07 March 2019

Date accepted : 18 March 2019

Funding

Funded by: Frank Edward Elmore Fund;

Funded by: National Institute of Health Research Cambridge Biomedical Research Centre;

Funded by: FundRef http://dx.doi.org/10.13039/501100000265, Medical Research Council;

Award ID: 1966157

Funded by: The Higher Education Funding Council for England;

Funded by: The British Heart Foundation;

Funded by: EPSRC;

Funded by: FundRef http://dx.doi.org/10.13039/100004440, Wellcome Trust;

Custom metadata

special-feature unlocked

Keywords: coronary artery disease,chest pain clinic,ct scanning,risk stratification

Data availability:

Keywords: coronary artery disease, chest pain clinic, ct scanning, risk stratification

A zero coronary artery calcium score in patients with stable chest pain is associated with a good prognosis, despite risk of non-calcified plaques

Read this article at

Abstract

Objectives

Methods

Results

Conclusion

Related collections

Cardiovascular Innovations and Applications

Most cited references 13

Diagnostic and prognostic value of absence of coronary artery calcification.

The Updated NICE Guidelines: Cardiac CT as the First-Line Test for Coronary Artery Disease

Author and article information

Journal

Affiliations

Author notes

Author information

Article

History

Funding

Categories

Custom metadata

Comments

Comment on this article

Similar content 193

Cited by 15

Most referenced authors 296