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Author Spotlight: Advancing Cardiovascular Imaging - Introducing the Spatially Weighted Calcium Score for Early Disease Detection
Published on: September 22, 2023
Coronary calcium score in the initial evaluation of suspected coronary artery disease
Eva Ringdal Pedersen1,2, Siren Hovland2, Iman Karaji3,2
1Department of Clinical Science, University of Bergen, Bergen, Norway evpe@helse-bergen.no.
Insights
Coronary artery calcium (CAC) scoring effectively rules out obstructive coronary artery disease (CAD) in symptomatic patients. However, younger patients (<45 years) may require further testing for definitive diagnosis.
Area of Science:
- Cardiology
- Radiology
- Preventive Medicine
Background:
- Coronary artery disease (CAD) is a leading cause of mortality.
- Early and accurate diagnosis of CAD is crucial for effective patient management.
- Coronary CT angiography (CCTA) is a standard diagnostic tool, but its widespread use may be limited by cost and radiation exposure.
Purpose of the Study:
- To evaluate the utility of coronary artery calcium (CAC) scoring as an initial diagnostic tool for suspected coronary artery disease (CAD).
- To assess the role of CAC scoring in triaging outpatients and emergency department patients.
- To determine the accuracy of CAC scoring in identifying obstructive and high-risk CAD.
Main Methods:
- A registry-based cross-sectional study involving 10,857 patients who underwent both CAC scoring and CCTA.
- Obstructive CAD was defined as ≥50% coronary stenosis on CCTA.
- High-risk CAD criteria were established based on specific stenosis locations and territories.
Main Results:
- The overall prevalence of CAC=0 was 45.0%.
- CAC=0 demonstrated a high negative predictive value (NPV) of 98.2% for obstructive CAD in symptomatic patients.
- In patients <45 years, the sensitivity of CAC=0 for obstructive CAD was lower (82.3%) despite a high NPV (98.9%).
Conclusions:
- CAC=0 effectively rules out obstructive CAD and high-risk CAD in the majority of symptomatic patients.
- CAC testing can serve as an initial gatekeeper to further cardiac investigations.
- Full CCTA may be necessary for younger patients (<45 years) to definitively rule out obstructive CAD.
Objective:
We evaluated coronary artery calcium (CAC) scoring as an initial diagnostic tool in outpatients and in patients presenting at the emergency department due to suspected coronary artery disease (CAD).
Methods:
10 857 patients underwent CAC scoring and coronary CT angiography (CCTA) at Haukeland University Hospital in Norway during 2013-2020. Based on CCTA, obstructive CAD was defined as at least one coronary stenosis ≥50%. High-risk CAD included obstructive stenoses of the left main stem, the proximal left ascending artery or affecting all three major vascular territories with at least one proximal segment involved.
Results:
Median age was 58 years and 49.5% were women. The overall prevalence of CAC=0 was 45.0%. Among those with CAC=0, 1.8% had obstructive CAD and 0.6% had high-risk CAD on CCTA. Overall, the sensitivity, specificity, positive predictive value and negative predictive value (NPV) of CAC=0 for obstructive CAD were 95.3%, 53.4%, 30.0% and 98.2%, respectively. However, among patients <45 years of age, although the NPV was high at 98.9%, the sensitivity of CAC=0 for obstructive CAD was only 82.3%.
Conclusions:
In symptomatic patients, CAC=0 correctly ruled out obstructive CAD and high-risk CAD in 98.2% and 99.4% of cases. This large registry-based cross-sectional study supports the incorporation of CAC testing in the early triage of patients with chest pain and as a gatekeeper to further cardiac testing. However, a full CCTA may be needed for safely ruling out obstructive CAD in the youngest patients (<45 years of age).
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