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Identifying Coronary Artery Calcification on Non-gated Computed Tomography Scans
Published on: August 28, 2018
Clinical decision aids and computed tomography coronary angiography in patients with suspected acute coronary
Kang-Ling Wang1,2,3, Caelan Taggart4,5, Michael McDermott4
1Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK k.l.wang@ed.ac.uk.
Insights
Combining CT coronary angiography (CTCA) with the T-MACS model significantly improves the diagnosis of acute coronary syndrome and prediction of revascularization in intermediate-risk patients. This approach offers better accuracy than traditional scores alone.
Area of Science:
- Cardiology
- Medical Imaging
- Clinical Decision Support
Background:
- Traditional risk scores (HEART, T-MACS, GRACE) aid acute chest pain decision-making.
- CT coronary angiography (CTCA) can complement these scores.
- Direct performance comparisons between these tools were lacking.
Purpose of the Study:
- To compare the diagnostic and predictive performance of clinical decision aids and CTCA.
- To evaluate CTCA alone and in combination with clinical decision aids.
- To assess their utility in intermediate-risk patients with suspected acute coronary syndrome.
Main Methods:
- Secondary analysis of a multicenter randomized controlled trial.
- Inclusion of intermediate-risk patients with suspected acute coronary syndrome who underwent CTCA.
- Assessment of C-statistics and performance metrics for index diagnosis and 30-day revascularization.
Main Results:
- CTCA showed higher C-statistics (0.80) than T-MACS (0.78), HEART (0.74), and GRACE (0.60) for acute coronary syndrome diagnosis.
- CTCA had a high negative predictive value (0.90) for coronary artery disease absence.
- Combination of T-MACS and CTCA yielded the highest C-statistics for diagnosis (0.88) and revascularization prediction (0.85).
Conclusions:
- The T-MACS model combined with CTCA enhances the diagnosis of acute coronary syndrome.
- This combination improves the prediction of 30-day coronary revascularization in intermediate-risk patients.
- Patients with low T-MACS scores and normal CTCA had excellent short-term outcomes.
Background:
The HEART score, the T-MACS model and the GRACE score support early decision-making for acute chest pain, which could be complemented by CT coronary angiography (CTCA). However, their performance has not been directly compared.
Methods:
In this secondary analysis of a multicentre randomised controlled trial of early CTCA in intermediate-risk patients with suspected acute coronary syndrome, C-statistics and performance metrics (using the predefined cut-offs) of clinical decision aids and CTCA, alone and then in combination, for the index hospital diagnosis of acute coronary syndrome and for 30-day coronary revascularisation were assessed in those who underwent CTCA and had complete data.
Results:
Among 699 patients, 358 (51%) had an index hospital diagnosis of acute coronary syndrome, for which the C-statistic was higher for CTCA (0.80), followed by the T-MACS model (0.78), the HEART score (0.74) and the GRACE score (0.60). The negative predictive value was higher for the absence of coronary artery disease on CTCA (0.90) or a T-MACS estimate of <0.05 (0.83) than a HEART score of <4 (0.81) and a GRACE score of <109 (0.55). For 30-day coronary revascularisation, CTCA had the greatest C-statistic (0.80) with a negative predictive value of 0.96 and 0.92 in the absence of coronary artery disease and obstructive coronary artery disease, respectively. The combination of the T-MACS estimates and the CTCA findings was most discriminative for the index hospital diagnosis of acute coronary syndrome (C-statistic, 0.88) and predictive of 30-day coronary revascularisation (C-statistic, 0.85). No patients with a T-MACS estimate of <0.05 and normal coronary arteries had acute coronary syndrome during index hospitalisation or underwent coronary revascularisation within 30 days.
Conclusions:
In intermediate-risk patients with suspected acute coronary syndrome, the T-MACS model combined with CTCA improved discrimination of the index hospital diagnosis of acute coronary syndrome and prediction of 30-day coronary revascularisation.
Trial Registration Number:
NCT02284191.
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