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Signal Acquisition, Score Interpretation, and Economics of a Non-Invasive Point-of-Care Test for Coronary Artery Disease
Published on: August 9, 2024
Absent or Mild Coronary Calcium Predicts Low-Risk Stress Test Results and Outcomes in Patients Considered for
Jeffrey L Anderson1,2, Stacey Knight1, Raymond O McCubrey1
1Intermountain Medical Center, 98078Intermountain Heart Institute, Salt Lake City, UT, USA.
Insights
Coronary artery calcium (CAC) scans can help identify atrial fibrillation (AF) patients suitable for flecainide by assessing ischemic burden. Absent or mild CAC may reduce the need for stress testing in these patients.
Area of Science:
- Cardiology
- Medical Imaging
- Pharmacology
Background:
- Flecainide is an antiarrhythmic for atrial fibrillation (AF).
- Ventricular proarrhythmia risk excludes flecainide in patients with myocardial infarction (MI) or coronary artery disease (CAD).
- Stress testing is currently used to exclude myocardial ischemia.
Purpose of the Study:
- To evaluate if absent/mild coronary artery calcium (CAC) can supplement or replace stress testing.
- To assess the relationship between CAC burden and ischemic burden in AF patients.
- To determine clinical outcomes associated with different CAC burdens.
Main Methods:
- 1372 AF patients (≥50 years) without clinical CAD symptoms underwent regadenoson Rb-82 PET/CT for ischemic burden assessment.
- Coronary artery calcium (CAC) was determined by qualitative or quantitative CT.
- Ischemic burden and clinical outcomes were compared based on CAC burden.
Main Results:
- Patients with absent/mild CAC (57.2%) were younger, more female, had higher BMI, but lower rates of traditional cardiovascular risk factors.
- Absent/mild CAC was associated with lower average ischemic burden, greater coronary flow reserve, and fewer referrals for angiography or revascularization.
- Longer-term major adverse cardiovascular events were favorable in the absent/mild CAC group.
Conclusions:
- Low-radiation CAC scans can identify AF patients with low ischemic burden, potentially avoiding extensive cardiac workup.
- Absent or mild CAC, combined with clinical data, may reduce or replace routine stress testing for flecainide candidacy.
- Further randomized trials are needed to confirm if CAC screening can replace stress testing in clinical practice for flecainide selection.
Background:
Flecainide is a useful antiarrhythmic for atrial fibrillation (AF). However, because of ventricular proarrhythmia risk, a history of myocardial infarction (MI) or coronary artery disease (CAD) is a flecainide exclusion, and stress testing is used to exclude ischemia. We assessed whether absent/mild coronary artery calcium (CAC) can supplement or avoid the need for stress testing.
Methods:
We assessed ischemic burden using regadenoson Rb-82 PET/CT in 1372 AF patients ≥50 years old without symptoms or signs of clinical CAD. CAC was determined qualitatively by low dose attenuation computed tomography (CT) (n = 816) or by quantitative CT (n = 556). Ischemic burden and clinical outcomes were compared by CAC burden.
Results:
Patients with CAC absent or mild (n = 766, 57.2%) were younger, more frequently female, and had higher BMI but lower rates of diabetes, hypertension, and dyslipidemia. Average ischemic burden was lower in CAC-absent/mild patients, and CAC-absent/mild patients showed greater coronary flow reserve, had fewer referrals for coronary angiography, and less often had obstructive CAD. Revascularization at 90 days was lower, and the rate of longer-term major adverse cardiovascular events was favorable.
Conclusions:
An easily administered, inexpensive, low radiation CAC scan can identify a subset of flecainide candidates with a low ischemic burden on PET stress testing that rarely needs coronary angiography/intervention and has favorable outcomes. Absent or mild CAC-burden combined with other clinical information may avoid or complement routine stress testing. However, additional, ideally randomized and multicenter trials are indicated to confirm these findings before replacing stress testing with CAC screening in selecting patients for flecainide therapy in clinical practice.
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