Coronary artery disease
Impact of Clinical Presentation and Pretest Likelihood on the Relation Between Calcium Score and Computed Tomographic Coronary Angiography

https://doi.org/10.1016/j.amjcard.2010.08.014Get rights and content

The purpose of the present study was to assess the impact of clinical presentation and pretest likelihood on the relation between coronary calcium score (CCS) and computed tomographic coronary angiography (CTA) to determine the role of CCS as a gatekeeper to CTA in patients presenting with chest pain. In 576 patients with suspected coronary artery disease (CAD), CCS and CTA were performed. CCS was categorized as 0, 1 to 400, and >400. On CT angiogram the presence of significant CAD (≥50% luminal narrowing) was determined. Significant CAD was observed in 14 of 242 patients (5.8%) with CCS 0, in 94 of 260 patients (36.2%) with CCS 1 to 400, and in 60 of 74 patients (81.1%) with CCS >400. In patients with CCS 0, prevalence of significant CAD increased from 3.9% to 4.1% and 14.3% in nonanginal, atypical, and typical chest pain, respectively, and from 3.4% to 3.9% and 27.3% with a low, intermediate, and high pretest likelihood, respectively. In patients with CCS 1 to 400, prevalence of significant CAD increased from 27.4% to 34.7% and 51.7% in nonanginal, atypical, and typical chest pain, respectively, and from 15.4% to 35.6% and 50% in low, intermediate, and high pretest likelihood, respectively. In patients with CCS >400, prevalence of significant CAD on CT angiogram remained high (>72%) regardless of clinical presentation and pretest likelihood. In conclusion, the relation between CCS and CTA is influenced by clinical presentation and pretest likelihood. These factors should be taken into account when using CCS as a gatekeeper for CTA.

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Methods

The study population consisted of patients with suspected CAD who were clinically referred for further cardiac assessment because of chest pain. The included patients underwent CCS scanning and CTA. Exclusion criteria were cardiac arrhythmias, renal insufficiency (defined as glomerular filtration rate <30 ml/min), known hypersensitivity to iodine contrast media, severe claustrophobia, and pregnancy. In addition, patients with an uninterpretable CT angiographic examination were excluded.

Results

The study population consisted of 602 patients presenting with chest pain who had undergone CCS and CTA. In 26 of these patients (4.3%), CT angiographic examination was uninterpretable because of the presence of motion artifacts, increased noise owing to a high body mass index, and breathing. After exclusion of these patients, 576 remained for further analysis. Baseline characteristics of the patient population are presented in Table 1.

Median CCS of the study population was 7 (25th to 75th

Discussion

The main finding of the present study is that the relation between CCS and CTA is strongly influenced by clinical presentation and pretest likelihood in patients presenting with chest pain. In each CCS category, prevalence of significant CAD on CT angiogram increased proportional to the severity of clinical presentation and pretest likelihood. Clinical presentation and pretest likelihood should therefore be taken into account when using CCS as a gatekeeper for CTA.

Several previous studies have

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Dr. van Werkhoven is financially supported by a research grant from the Netherlands Society of Cardiology, Utrecht, The Netherlands. Dr. Boogers is supported Grant 2006T102 from the Dutch Heart Foundation, Utrecht, The Netherlands. Dr. Bax has research grants from Medtronic, Tolochenaz, Switzerland; Boston Scientific, Maastricht, The Netherlands; BMS Medical Imaging, N. Billerica, Massachusetts; St. Jude Medical, Veenendaal, The Netherlands; Biotronik, Berlin, Germany; GE Healthcare, St. Giles, United Kingdom; and Edwards Lifesciences, Saint-Prex, Switzerland.

Dr. van Werkhoven and Ms. de Boer contributed equally to this work.

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