Does Coronary Artery Calcium Scoring Add to the Predictive Value of Coronary Computed Tomography Angiography for Adverse Cardiovascular Events in Low‐risk Chest Pain Patients?

Chang, Anna Marie; Le, Jeffrey; Matsuura, Asako C.; Litt, Harold; Hollander, Judd E.

doi:10.1111/j.1553-2712.2011.01173.x

Cited by 24 publications

(15 citation statements)

References 46 publications

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“…A total of 72 patients had a CACS of 0, among whom 14 (19%) had at least 1 stenosis ≥50%. Chang et al 92 found that 4 of 17 patients (24%) with a CACS of 0 still had CAD. Within the CON-FIRM registry (Coronary Computed Tomography Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry), >5000 patients had a CACS of 0, yet 16% of these patients still had evidence of CAD on coronary CTA.…”

Section: Calcium Score Alonementioning

confidence: 99%

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

2016

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ABSTRACT:It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.A bout 20 million patients present with symptoms possibly suggestive of acute coronary syndrome (ACS) to emergency departments (ED) in North America and Europe each year.1-3 Patients with ACS and acute myocardial infarction (AMI) present with a wide variety of symptoms such as chest pain, shortness of breath, weakness, nausea, vomiting, and even fatigue, making the diagnosis difficult. Demographics, cardiac risk factors, chest pain characteristics, and physical examination can assist disposition decisions but are insufficient to identify who does and does not have an ACS.4-7 Some patients may have objective evidence of a clearcut diagnosis, but the majority do not. 8 The majority ultimately will be found not to have ACS, but symptoms caused by noncardiac and often benign disorders such as musculoskeletal pain, pleuritis, or gastroesophageal reflux make the rapid rule-out of ACS more difficult and result in huge medical expenses. Safe and early rule-out of ACS contributes to more efficient and high-value healthcare delivery. History And PHysicAl ExAminAtionClinical features, alone or in combination with an ECG, are poorly predictive for AMI (Table 1). 9,10 In addition, they have variable reliability. Features classically associated with a lower probability of AMI such as pleuritic, positional, and sharp chest pain have poor to fair interphysician reliability (κ=0.27-0.44), 11 whereas high-risk features (radiation to left arm, substernal location, and history of AMI) are more reliable (κ=0.74-0.89). 11Traditional cardiac risk factors, derived from population-based longitudinal cohort studies of asymptomatic patients, are poor predictors of risk for AMI or ACS in symptomatic patients in the ED. 6,7 Similarly, the physical examination seldom is useful for distinguishing patients with ACS from patients with noncardiac chest pain.Trials of medications, onc...

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Section: Calcium Score Alonementioning

confidence: 99%

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

2016

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“…Of note, half of those with zero CACS and an adverse outcome had increased troponin measured by conventional assays (5,(8)(9)(10).…”

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Low High-Sensitivity Troponin I and Zero Coronary Artery Calcium Score Identifies Coronary CT Angiography Candidates in Whom Further Testing Could be Avoided

Korley¹,

George²,

Jaffe³

et al. 2015

Academic Radiology

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“…Initially, 952 articles were identified for screening, 81 met criteria for full‐text review, and 33 articles were included in this meta‐analysis. Of the 33 studies, seven were randomized controlled trials, 30–36 17 were prospective cohort studies, 37–53 and the remaining nine were retrospective cohort studies 54–62 …”

Section: Resultsmentioning

confidence: 99%

Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta‐analysis

Mehta

McDonald

Hirani

et al. 2021

Academic Emergency Medicine

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Objectives Our primary objective was to describe the risk of major adverse cardiac events (MACE) at 1, 6, and 12 months after a negative coronary computed tomography angiogram (cCTA), electrocardiogram (ECG) stress test, stress echocardiography, and myocardial perfusion scintigraphy (MPS) in low‐ to intermediate‐risk patients. Methods Initially, 952 articles were identified for screening, 81 met criteria for full‐text review, and once risk of bias was assessed, 33 articles were included in this meta‐analysis. We utilized a random‐effects model to assess pooled MACE event proportion for patients undergoing evaluation of acute coronary syndrome (ACS) when risk stratified to a low‐ to intermediate‐risk category after undergoing standard testing. Heterogeneity analysis was performed using Cochrane's Q‐test and I2 statistic. Results Twenty‐one studies evaluated follow‐up at 1 month with cCTA having a 0.09% (95% confidence interval [CI] = 0.03% to 0.26%) pooled MACE compared to 0.23% (95% CI = 0.01% to 5.8%) of the exercise stress testing (p = 1). MPS and cCTA had an overall event rate of 0.15% (95% CI = 0.06% to 0.41%) at 6 months (I2 = 0%). At 12 months, a subgroup analysis found a pooled cCTA MACE of 0.16% (95% CI = 0.04% to 0.65%) compared to 1.68% (95% CI = 0.01% to 2.6%) for stress echocardiography with low within‐group heterogeneity (I2 = 0%). Subgroup analysis of cCTA with no disease versus nonobstructive disease (<50% stenosis) did not find statistical difference in the MACE at both 1 month (0.17% [95% CI = 0.04% to 0.67%] vs. 0.06% [95% CI = 0.01% to 0.34%]) and 12 months (0.44% [95% CI = 0.09% to 2.2% vs. 0.54% [95% CI = 0.19% to 1.5%]). Conclusions Patients presenting with chest pain who have a coronary CTA showing < 50% stenosis, negative ECG stress test, stress echocardiography, or stress myocardial perfusion scan in the past 12 months can be discharged without any further risk stratification if their ECG and troponin are reassuring given low MACE.

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Does Coronary Artery Calcium Scoring Add to the Predictive Value of Coronary Computed Tomography Angiography for Adverse Cardiovascular Events in Low‐risk Chest Pain Patients?

Cited by 24 publications

References 46 publications

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

Low High-Sensitivity Troponin I and Zero Coronary Artery Calcium Score Identifies Coronary CT Angiography Candidates in Whom Further Testing Could be Avoided

Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta‐analysis

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