Prevalence and Extent of Obstructive Coronary Artery Disease in Patients With Zero or Low Calcium Score Undergoing 64-Slice Cardiac Multidetector Computed Tomography for Evaluation of a Chest Pain Syndrome

Rubinshtein, Ronen; Gaspar, Tamar; Halon, David A.; Goldstein, Jacob; Peled, Nathan; Lewis, Basil S.

doi:10.1016/j.amjcard.2006.08.060

Cited by 153 publications

(108 citation statements)

References 13 publications

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“…Patients with CTCA evidence of significant stenosis should undergo further functional imaging (nuclear stress test, stress echocardiography, MRI perfusion test) to exclude significant ischemia. NICE guidelines suggest that patients with low likehood of CAD should undergo CT calcium scoring, and CTCA if calcium score is 1-400.19 However this pathway we will misdiagnose around 10% of patients with CAC score 0 and atherosclerosis due to non-calcified plaque (30)(31)(32). Finally, the European society of cardiology guidelines (2006) recommend the CTCA in patients with a low pretest probability, with a non-conclusive exercise ECG or stress imaging test (level of evidence C) (33).…”

Section: Discussionmentioning

confidence: 99%

Computed Tomography Coronary Angiography as Initial Work-Up for Unstable Angina Pectoris

Koulaouzidis

Powell²,

McArthur³

et al. 2012

ELECTRON J GEN MED

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Section: Discussionmentioning

confidence: 99%

Computed Tomography Coronary Angiography as Initial Work-Up for Unstable Angina Pectoris

Koulaouzidis

Powell²,

McArthur³

et al. 2012

ELECTRON J GEN MED

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“…25 Coronary artery stenoses are rare in patients without CAC in most studies. 15,26 However, Rubinshtein et al 27 found that CAD was evident on cardiac CT angiography (CTA) in 7% of patients with CAC scores of 0. These data are not directly comparable to the findings of our study because of the differences in study populations and end points.…”

Section: Discussionmentioning

confidence: 99%

Computed Tomographic Coronary Artery Calcium Assessment for Evaluating Chest Pain in the Emergency Department: Long-term Outcome of a Prospective Blind Study

Laudon¹,

Behrenbeck²,

Wood

et al. 2010

Mayo Clinic Proceedings

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For editorial comment, see page 309 C hest pain is the presenting concern for more than 8 million emergency department (ED) visits annually. The ED evaluation of chest pain is resource-intense and has inherent limitations. Medical history and physical examination frequently yield little insight into the source of the chest pain. More than one-third of patients with docu- OBJECTIVE: To determine the long-term outcome of computed tomographic (CT) quantification of coronary artery calcium (CAC) used as a triage tool for patients presenting with chest pain to an emergency department (ED). PATIENTS AND METHODS:Patients (men aged 30-62 years and women aged 30-65 years) with chest pain and low-to-moderate probability of coronary artery disease underwent both conventional ED chest pain evaluation and CT CAC assessment prospectively. Patients' physicians were blinded to the CAC results. The results of the conventional evaluation were compared with CAC findings on CT, and the long-term outcome in patients undergoing CT CAC assessment was established. Primary end points (acute coronary syndrome, death, fatal or nonfatal non-ST-segment elevation myocardial infarction, fatal or nonfatal ST-segment elevation myocardial infarction) and secondary outcomes (coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, coronary stenting, or a combination thereof) were obtained when the patient was dismissed from the ED or hospital and then at 30 days, 1 year, and 5 years. RESULTS:Of the 263 study patients, 133 (51%) had a CAC score of zero. This absence of CAC correlated strongly with the likelihood of noncardiac chest pain. Among 133 patients with a CAC score of zero, only 1 (<1%) had cardiac chest pain. Conversely, of the 31 patients shown to have cardiac chest pain, 30 (97%) had evidence of CAC on CT. When a CAC cutoff score of 36 was used, as suggested by receiver operating characteristic analysis, sensitivity was 90%; specificity, 85%; positive predictive value, 44%; and negative predictive value, 99%. During long-term follow-up, patients without CAC experienced no cardiac events at 30 days, 1 year, and 5 years.CONCLUSION: Findings suggest that CT CAC assessment is a powerful adjunct in chest pain evaluation for the population at low-tointermediate risk. Absent or minimal CAC in this population makes cardiac chest pain extremely unlikely. The absence of CAC suggests an excellent long-term (5-year) prognosis, with no primary or secondary cardiac outcomes ocurring in study patients at 5-year follow-up. Proc. 2010;85(4):314-322 ACS = acute coronary syndrome; CAC = coronary artery calcium; CAD = coronary artery disease; CI = confidence interval; CT = computed tomography; CTA = CT angiography; ECG = electrocardiography; ED = emergency department; IQR = interquartile range; MDCT = multidetector CT; MI = myocardial infarction; ROC = receiver operating characteristic mented acute myocardial infarctions (MIs) lack chest pain on presentation. Mayo Clin2 Resting 12-lead electrocardiography (ECG) has limited value in ...

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“…Significant or obstructive CAD was defined as C50% luminal diameter narrowing and considered moderate or severe when causing 50%-70% or [70% stenosis, respectively. 25,26 Plaques causing \50% stenosis were considered non-significant disease. Non-diagnostic results of CCTA were considered when any coronary segment was not evaluable because of motion artifacts, calcification, or low contrast-to-noise ratio.…”

Section: Cta Protocolsmentioning

confidence: 99%

A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department

Duvall

Savino

Levine

et al. 2014

Journal of Nuclear Cardiology

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Background. Recent studies have compared CTA to stress testing and MPI using older Na-I SPECT cameras and traditional rest-stress protocols, but are limited by often using optimized CTA protocols but suboptimal MPI methodology. We compared CTA to stress testing with modern SPECT MPI using high-efficiency CZT cameras and stress-first protocols in an ED population.Methods. In a retrospective, non-randomized study, all patients who underwent CTA or stress testing (ETT or Tc-99m sestamibi SPECT MPI) as part of their ED assessment in 2010-2011 driven by ED attending preference and equipment availability were evaluated for their disposition from the ED (admission vs discharge, length of time to disposition), subsequent visits to the ED and diagnostic testing (within 3 months), and radiation exposure. CTA was performed using a 64-slice scanner (GE Lightspeed VCT) and MPI was performed using a CZT SPECT camera (GE Discovery 530c). Data were obtained from prospectively acquired electronic medical records and effective doses were calculated from published conversion factors. A propensity-matched analysis was also used to compare outcomes in the two groups.Results. A total of 1,458 patients underwent testing in the ED with 192 CTAs and 1,266 stress tests (327 ETTs and 939 MPIs). The CTA patients were a lower-risk cohort based on age, risk factors, and known heart disease. A statistically similar proportion of patients was discharged directly from the ED in the stress testing group (82% vs 73%, P 5 .27), but their time to disposition was longer (11.0 ± 5 vs 20.5 ± 7 hours, P < .0001). There was no significant difference in cardiac return visits to the ED (5.7% CTA vs 4.3% stress testing, P 5 .50), but more patients had follow-up studies in the CTA cohort compared to stress testing (14% vs 7%, P 5 .001). The mean effective dose of 12.6 ± 8.6 mSv for the CTA group was higher (P < .0001) than 5.0 ± 4.1 mSv for the stress testing group (ETT and MPI). A propensity score-matched cohort showed similar results to the entire cohort.Conclusions. Stress testing with ETT, high-efficiency SPECT MPI, and stress-only protocols had a significantly lower patient radiation dose and less follow-up diagnostic testing than CTA with similar cardiac return visits. CTA had a shorter time to disposition, but there was a trend toward more revascularization than with stress testing. (J Nucl Cardiol 2014;21:305-18.)

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Prevalence and Extent of Obstructive Coronary Artery Disease in Patients With Zero or Low Calcium Score Undergoing 64-Slice Cardiac Multidetector Computed Tomography for Evaluation of a Chest Pain Syndrome

Cited by 153 publications

References 13 publications

Computed Tomography Coronary Angiography as Initial Work-Up for Unstable Angina Pectoris

Computed Tomography Coronary Angiography as Initial Work-Up for Unstable Angina Pectoris

Computed Tomographic Coronary Artery Calcium Assessment for Evaluating Chest Pain in the Emergency Department: Long-term Outcome of a Prospective Blind Study

A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department

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