The Absence of Coronary Calcification Does Not Exclude Obstructive Coronary Artery Disease or the Need for Revascularization in Patients Referred for Conventional Coronary Angiography
This study was designed to evaluate whether the absence of coronary calcium could rule out ≥50% coronary stenosis or the need for revascularization.
Background
The latest American Heart Association guidelines suggest that a calcium score (CS) of zero might exclude the need for coronary angiography among symptomatic patients.
Methods
A substudy was made of the CORE64 (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors) multicenter trial comparing the diagnostic performance of 64-detector computed tomography to conventional angiography. Patients clinically referred for conventional angiography were asked to undergo a CS scan up to 30 days before.
Results
In all, 291 patients were included, of whom 214 (73%) were male, and the mean age was 59.3 ± 10.0 years. A total of 14 (5%) patients had low, 218 (75%) had intermediate, and 59 (20%) had high pre-test probability of obstructive coronary artery disease. The overall prevalence of ≥50% stenosis was 56%. A total of 72 patients had CS = 0, among whom 14 (19%) had at least 1 ≥50% stenosis. The overall sensitivity for CS = 0 to predict the absence of ≥50% stenosis was 45%, specificity was 91%, negative predictive value was 68%, and positive predictive value was 81%. Additionally, revascularization was performed in 9 (12.5%) CS = 0 patients within 30 days of the CS. From a total of 383 vessels without any coronary calcification, 47 (12%) presented with ≥50% stenosis; and from a total of 64 totally occluded vessels, 13 (20%) had no calcium.
Conclusions
The absence of coronary calcification does not exclude obstructive stenosis or the need for revascularization among patients with high enough suspicion of coronary artery disease to be referred for coronary angiography, in contrast with the published recommendations. Total coronary occlusion frequently occurs in the absence of any detectable calcification. (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors [CORE-64]; NCT00738218)
Key Words
coronary artery disease
calcium score
computed tomography
coronary angiography
coronary stenosis
Abbreviations and Acronyms
AHA
American Heart Association
AUC
area under the receiver-operating characteristic curve
CAD
coronary artery disease
CCA
conventional coronary angiography
CI
confidence interval
CS
calcium score
ECG
electrocardiogram
ED
emergency department
MDCT
multidetector computed tomography
OR
odds ratio
QCA
quantitative coronary angiography
Cited by (0)
Continuing Medical Education (CME) is available for this article.
This study is supported by grants from Toshiba Medical Systems, the Doris Duke Charitable Foundation, the National Heart, Lung, and Blood Institute(RO1-HL66075-01 and HO1-HC95162-01), the National Institute on Aging(RO1-AG021570-01), and the Donald W. Reynolds Foundation. Dr. Miller receives grant support from Toshiba Medical Systems. Dr. Dewey receives speaker's fees from Bayer, Schering, and Toshiba Medical Systems and grant support from GE Healthcare, Bracco, and Toshiba Medical Systems. Dr. Bush receives speaker's fees from Bristol-Myers Squibb, Sanofi-Aventis, and Toshiba Medical Systems. Dr. Paul receives advisory fees from Vital Images and grant support and speakers' fees from Toshiba Medical Systems. Dr. Lima receives grant support from GE Medical Systemsand grant support and speakers' fees from Toshiba Medical Systems.
Rita Redberg, MD, served as Guest Editor for this article.
