Coronary artery disease
Diagnostic Value of Coronary Artery Calcium Scoring in Low-Intermediate Risk Patients Evaluated in the Emergency Department for Acute Coronary Syndrome

https://doi.org/10.1016/j.amjcard.2010.08.037Get rights and content

Early and accurate triage of patients with possible ischemic chest pain remains challenging in the emergency department because current risk stratification techniques have significant cost and limited availability. The aim of this study was to determine the diagnostic value of the coronary artery calcium score (CACS) for the detection of obstructive coronary artery disease (CAD) in low- to intermediate-risk patients evaluated in the emergency department for suspected acute coronary syndromes. A total of 225 patients presenting to the emergency department with acute chest pain and Thrombolysis In Myocardial Infarction (TIMI) scores <4 who underwent non-contrast- and contrast-enhanced coronary computed tomographic angiography were included. CACS was calculated from the noncontrast scan using the Agatston method. The prevalence of obstructive CAD (defined from the contrast scan as ≥50% maximal reduction in luminal diameter in any segment) was 9% and increased significantly with higher scores (p <0.01 for trend). CACS of 0 were observed in 133 patients (59%), of whom only 2 (1.5%) had obstructive CAD. The diagnostic accuracy of CACS to detect obstructive CAD was good, with an area under the receiver-operating characteristic curve of 0.88 and a negative predictive value of 99% for a CACS of 0. In a multivariate model, CACS was independently associated with obstructive CAD (odds ratio 7.01, p = 0.02) and provided additional diagnostic value over traditional CAD risk factors. In conclusion, CACS appears to be an effective initial tool for risk stratification of low- to intermediate-risk patients with possible acute coronary syndromes, on the basis of its high negative predictive value and additive diagnostic value.

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Methods

From March 2007 to January 2009, all consecutive patients who were evaluated in the ED for suspected ACS with nondiagnostic electrocardiographic findings and negative initial cardiac troponin and subsequently underwent CCTA and coronary artery calcium scoring were retrospectively studied. Exclusion criteria included known significant coronary artery disease (CAD), defined as coronary artery stenosis ≥50% and/or previous coronary revascularization. Troponin I was considered negative when <0.5

Results

From March 2007 to January 2009, 247 consecutive patients presenting to the ED with suspected ACS underwent CCTA. Of them, 22 patients did not have calcium score scans performed, because of histories of coronary revascularization or young age (<30 years). Therefore, the final cohort consisted of 225 patients. Study population characteristics are listed in Table 1. The prevalence of significant CAD was 9% and increased along with higher pretest probability and higher TIMI risk score (Figure 2).

Discussion

The main finding of our study is that a CACS of 0 demonstrated a high negative predictive value to exclude significant CAD in low- to intermediate-risk patients presenting to the ED with acute chest pain and provided additional diagnostic value over CAD risk factors. The negative predictive value and the sensitivity of a CACS of 0 to exclude significant CAD in our study population were high (99% and 91%, respectively). Indeed, only 2 patients with absence of calcification had moderate lesions

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Cited by (39)

  • Coronary Calcium to Rule Out Obstructive Coronary Artery Disease in Patients With Acute Chest Pain

    2022, JACC: Cardiovascular Imaging
    Citation Excerpt :

    Studies have evaluated the diagnostic accuracy of CAC testing to rule out obstructive CAD on CCTA among low- to intermediate-risk patients in the ED. Among these studies, the prevalence of patients without any CAC ranged from 36% to 75%, and the prevalence of obstructive CAD among those with CAC = 0 ranged from 1.8% to 5.2% (10,11). Additionally, CAC testing ruled out obstructive CAD with a sensitivity of 91% to 100% and an NPV of 94% to 100%.

  • Geographic and Individual Correlates of Subclinical Atherosclerosis in an Asymptomatic Rural Appalachian Population

    2018, American Journal of the Medical Sciences
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    Perhaps, CAC screening can be incorporated in CV healthcare in such a high CVD prevalence environment, given that presence of calcification in coronary arteries is a quantifiable marker for coronary atherosclerosis and a measure of plaque burden,46,61-63 CAC is associated with the traditional CVD risk factors,64-71 and CAC improves CV risk prediction when added to traditional risk factors.6,72 Moreover, the expert consensus is that CAC screening is appropriate for individuals at intermediate risk on traditional risk assessment tools1,61,67,73,74 such as those in Central Appalachia where significant proportion of the population has more than 1 CVD risk factor.42 With the high prevalence of subclinical atherosclerosis among asymptomatic individuals, the key issue was identifying predisposition factors.

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This work was partially supported by Instituto de Formacion e Investigacion “Marques de Valdecilla,” Santander, Spain (PostMIR Wenceslao Lopez Albo grant to Dr. Fernandez-Friera), the Spanish Society of Cardiology (postresidency grant to Drs. Fernandez-Friera and Garcia-Alvarez), and Centro Nacional de Investigacion Cardiovascular, Madrid, Spain (Drs. Garcia-Alvarez and Mirelis).

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