Prevalence of obstructive coronary artery disease and prognosis in patients with stable symptoms and a zero-coronary calcium score

Abstract

AimsCT calcium scoring (CTCS) and CT cardiac angiography (CTCA) are widely used in patients with stable chest pain to exclude significant coronary artery disease (CAD). We aimed to resolve uncertainty about the prevalence of obstructive coronary artery disease and long-term outcomes in patients with a zero-calcium score (ZCS).Methods and resultsConsecutive patients with stable cardiac symptoms referred for CTCS or CTCS and CTCA from chest pain clinics to a tertiary cardiothoracic centre were prospectively enrolled. In those with a ZCS, the prevalence of obstructive CAD on CTCA was determined. A follow-up for all-cause mortality was obtained from the NHS tracer service. A total of 3914 patients underwent CTCS of whom 2730 (69.7%) also had a CTCA. Half of the patients were men (50.3%) with a mean age of 56.9 years. Among patients who had both procedures, a ZCS was present in 52.2%, with a negative predictive value of 99.5% for excluding ≥70% stenosis on CTCA. During a mean follow-up of 5.2 years, the annual event rate was 0.3% for those with ZCS compared with 1.2% for CS ≥1. The presence of non-calcified atheroma on CTCA in patients with ZCS did not affect the prognostic value (P = 0.98).ConclusionIn patients with stable symptoms and a ZCS, obstructive CAD is rare, and prognosis over the long-term is excellent, regardless of whether non-calcified atheroma is identified. A ZCS could reliably be used as a ‘gatekeeper’ in this patient cohort, obviating the need for further more expensive tests.

A zero coronary artery calcium score in patients with stable chest pain is associated with a good prognosis, despite risk of non-calcified plaques

“…In a single-centre prospective cohort study of 1114 patients, the prevalence of ≥50% stenosis was 4.3% 11. Negative predictive values of 99.5%, 99% and 96%, respectively, have been quoted in the literature,10 12 13 close to our findings. The negative predictive value for zero CAC compares well with CTCA and stress imaging tests 14…”

Standardized reporting systems for computed tomography coronary angiography and calcium scoring: A real-world validation of CAD-RADS and CAC-DRS in patients with stable chest pain

“…Similar to previous studies, patients with no coronary artery calcification were are at a lower, but not absent, risk of cardiac events. 21,23,24 Indeed, CCTA identified at-risk patients with plaque disease but a calcium score of zero. Thus, coronary artery calcification alone may lack sufficient sensitivity for the diagnosis of patients with suspected angina due to coronary heart disease.…”

Staged testing as a solution to the challenges of testing lower risk patients

“…10,11 Similar proposals 12,13 to use CAC as a gatekeeper for MPI are supported by large retrospective data sets from several nuclear laboratories showing a very low prevalence of ischemia and events in when CAC = 0. [14][15][16][17][18][19][20] In addition to significant value as a gatekeeper application with CAC = 0 used to limiting low-yield downstream testing, abnormal CAC testing provides additional value for a large majority of patients with normal MPI. Although expected to vary across populations, nearly one in four patients with normal MPI will have CAC [ 0.…”