Computed tomography angiography versus Agatston score for diagnosis of coronary artery disease in patients with stable chest pain: individual patient data meta-analysis of the international COME-CCT Consortium

Abstract

Objectives There is conflicting evidence about the comparative diagnostic accuracy of the Agatston score versus computed tomography angiography (CTA) in patients with suspected obstructive coronary artery disease (CAD). Purpose To determine whether CTA is superior to the Agatston score in the diagnosis of CAD. Methods In total 2452 patients with stable chest pain and a clinical indication for invasive coronary angiography (ICA) for suspected CAD were included by the Collaborative Meta-analysis of Cardiac CT (COME-CCT) Consortium. An Agatston score of > 400 was considered positive, and obstructive CAD defined as at least 50% coronary diameter stenosis on ICA was used as the reference standard. Results Obstructive CAD was diagnosed in 44.9% of patients (1100/2452). The median Agatston score was 74. Diagnostic accuracy of CTA for the detection of obstructive CAD (81.1%, 95% confidence interval [CI]: 77.5 to 84.1%) was significantly higher than that of the Agatston score (68.8%, 95% CI: 64.2 to 73.1%, p < 0.001). Among patients with an Agatston score of zero, 17% (101/600) had obstructive CAD. Diagnostic accuracy of CTA was not significantly different in patients with low to intermediate (1 to < 100, 100–400) versus moderate to high Agatston scores (401–1000, > 1000). Conclusions Results in our international cohort show CTA to have significantly higher diagnostic accuracy than the Agatston score in patients with stable chest pain, suspected CAD, and a clinical indication for ICA. Diagnostic performance of CTA is not affected by a higher Agatston score while an Agatston score of zero does not reliably exclude obstructive CAD. Key Points • CTA showed significantly higher diagnostic accuracy (81.1%, 95% confidence interval [CI]: 77.5 to 84.1%) for diagnosis of coronary artery disease when compared to the Agatston score (68.8%, 95% CI: 64.2 to 73.1%, p < 0.001). • Diagnostic performance of CTA was not affected by increased amount of calcium and was not significantly different in patients with low to intermediate (1 to <100, 100–400) versus moderate to high Agatston scores (401–1000, > 1000). • Seventeen percent of patients with an Agatston score of zero showed obstructive coronary artery disease by invasive angiography showing absence of coronary artery calcium cannot reliably exclude coronary artery disease.

Diagnostic Ability of Manual Calcification Length Assessment on Non-Electrocardiographically Gated Computed Tomography for Estimating the Presence of Coronary Artery Disease

“…The presence of significant obstructive (epicardial) CAD was defined as a diameter reduction of ≥50% on invasive angiography. In this international study, standard CACS > 400 reportedly had relatively high specificity and positive predictive value with an accuracy of around 70% for the presence of angiographically significant epicardial CAD, which may be in line with our results (i.e., 76%) [22]. In the COME-CCT Consortium study, the prevalence of significant obstructive CAD on invasive angiography in patients with standard CACS of 0, 1-99, 100-399, 400-999, and ≥1000 was 16.8%, 35.6%, 55.5%, 70.4%, and 78.5%, respectively [22].…”

“…The ROC curve analysis indicated that the best cut-off value of CACS for CAD was 398 in this study, which was close to the established threshold of 400 [1,11]. In the individual patient data meta-analysis of the international COME-CCT Consortium, a total of 2452 patients from 76 studies who underwent both CACS assessment on CT and invasive coronary angiography were included [22]. The presence of significant obstructive (epicardial) CAD was defined as a diameter reduction of ≥50% on invasive angiography.…”

“…Because all patients in this study underwent invasive angiography with clinical indications, the prevalence of CAD may have been higher than that in previous reports. In a recent study (n = 2452) in which all participants underwent coronary angiography, 44.9% had obstructive CAD, defined as coronary diameter stenosis > 50% on angiography [22]. Although ischemic and functional testing was not necessarily mandated [27], most patients with obstructive CAD underwent coronary revascularization in a real-world setting in the present study [28][29][30][31].…”

Imaging Early Life Cardiovascular Phenotype

“…In stable chest pain patients and negative CAC score, CTA has better diagnostic accuracy and can provide better prognostic information that includes coronary anatomy, assessing noncalcified plaque, characterization of plaque burden and plaque volume, which makes it a desirable tool to diagnose CAD in patients with chest pain or angina equivalent symptoms. [79][80][81] However, excessive radiation exposure and cost-effectiveness make CTA undesirable as a screening tool among low-risk patients and populations. 14 Table 1 describes the summary of selected studies that examine the role of coronary imaging in the development of atherosclerotic CVD.…”

The effect of LDL-C status on the association between increased coronary artery calcium score and compositional plaque volume progression in statins-treated diabetic patients: evaluated using serial coronary CTAs

“…Coronary artery calcium (CAC) accompanies the development of advanced atherosclerosis [24]. Society of cardiovascular computed tomography (SCCT) guidelines recommend considering CAC scans among asymptomatic individuals with a risk of ASCVD.…”