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Published on: August 28, 2018
Coronary Calcium to Rule Out Obstructive Coronary Artery Disease in Patients With Acute Chest Pain
Gowtham R Grandhi1, Reed Mszar2, Miguel Cainzos-Achirica3
1Miami Cardiac and Vascular Institute, Baptist Health of South Florida, Miami, Florida, USA; Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA.
Insights
Coronary artery calcium (CAC) scans effectively rule out obstructive coronary artery disease (CAD) in low-risk emergency department patients. A CAC score of 0 indicates no obstructive CAD or need for revascularization in over 99% of cases.
Area of Science:
- Cardiology
- Radiology
- Emergency Medicine
Background:
- Coronary artery calcium (CAC) scoring is not yet well-established for ruling out obstructive coronary artery disease (CAD) in the emergency department (ED).
- Evaluating patients with acute chest pain (CP) at low to intermediate risk for acute coronary syndrome (ACS) requires efficient diagnostic tools.
Purpose of the Study:
- To assess the utility of CAC scoring as an initial diagnostic tool to rule out obstructive CAD in ED patients with acute CP.
- To determine the diagnostic accuracy of CAC testing in identifying the need for coronary revascularization.
Main Methods:
- Analysis of a large registry of 5,192 patients presenting to the ED with CP and low to intermediate ACS risk.
- Patients underwent both CAC scoring and coronary computed tomography angiography (CCTA).
- Diagnostic accuracy metrics including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.
Main Results:
- A CAC score of 0 was observed in 56% of patients, with only 0.7% having obstructive CAD.
- CAC testing demonstrated a sensitivity of 96.2% and an NPV of 99.3% for obstructive CAD.
- The NPV for identifying the need for revascularization was 99.6%, with only 0.4% of patients with CAC=0 undergoing revascularization.
Conclusions:
- A CAC score of 0 is highly effective in ruling out obstructive CAD and the need for revascularization in low- to intermediate-risk ED patients with CP.
- Early integration of CAC testing can aid in the appropriate triage of patients, potentially reducing unnecessary further testing and invasive procedures.
- CAC scoring serves as a valuable tool for safely identifying individuals who can defer additional cardiac evaluations.
Objectives:
This study aimed to evaluate the ability of coronary artery calcium (CAC) as an initial diagnostic tool to rule out obstructive coronary artery disease (CAD) in a very large registry of patients presenting to the emergency department (ED) with acute chest pain (CP) who were at low to intermediate risk for acute coronary syndrome (ACS).
Background:
It is not yet well established whether CAC can be used to rule out obstructive CAD in the ED setting.
Methods:
We included patients from the Baptist Health South Florida Chest Pain Registry presenting to the ED with CP at low to intermediate risk for ACS (Thrombolysis In Myocardial Infarction risk score ≤2, normal/nondiagnostic electrocardiography, and troponin levels) who underwent CAC and coronary computed tomography angiography (CCTA) procedures for evaluation of ACS. To assess the diagnostic accuracy of CAC testing to diagnose obstructive CAD and identify the need for coronary revascularization during hospitalization, we estimated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV).
Results:
Our study included 5,192 patients (mean age: 53.5 ± 10.8 years; 46% male; 62% Hispanic). Overall, 2,902 patients (56%) had CAC = 0, of which 135 (4.6%) had CAD (114 [3.9%] nonobstructive and 21 [0.7%] obstructive). Among those with CAC >0, 23% had obstructive CAD. Sensitivity, specificity, PPV, and NPV of CAC testing to diagnose obstructive CAD were 96.2%, 62.4%, 22.4%, and 99.3%, respectively. The NPV for identifying those who needed revascularization was 99.6%. Among patients with CAC = 0, 11 patients (0.4%) underwent revascularization, and the number needed to test with CCTA to detect 1 patient who required revascularization was 264.
Conclusions:
In a large population presenting to ED with CP at low to intermediate risk, CAC = 0 was common. CAC = 0 ruled out obstructive CAD and revascularization in more than 99% of the patients, and <5% with CAC = 0 had any CAD. Integrating CAC testing very early in CP evaluation may be effective in appropriate triage of patients by identifying individuals who can safely defer additional testing and more invasive procedures.
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