Impact of using the 2024 ESC guideline-recommended method to estimate the likelihood of obstructive coronary disease - a cardiac CT study.

The U.S. multi-societal chest pain guideline – A quick look into a long-awaited document

Background The 2021 Guideline for the Evaluation of Chest Pain supports the use of coronary artery calcium (CAC) score as a reasonable first-line test to identify patients with a low likelihood of obstructive coronary artery disease (CAD) who may not require additional testing (class IIa, LOE B). However, a recent study from a large cohort of Northern European patients raised concerns about the added diagnostic value of CAC=0 in younger patients. The aim of this study was to assess the influence of age on the value of CAC=0 in symptomatic patients undergoing coronary computed tomography angiography (CCTA). Methods We conducted a two-center cross-sectional study assessing symptomatic patients with suspected CAD who underwent CAC score and CCTA. Key exclusion criteria were age <30 years, known CAD, suspected acute coronary syndrome, or symptoms other than chest pain or dyspnea. Pretest probability of obstructive CAD was calculated based on age, sex and symptom typicality, according to the guideline-recommended method. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. The diagnostic likelihood ratios and negative predictive values (NPV) were used to assess the diagnostic value of a CAC score of 0 to rule out obstructive CAD. Results A total of 2043 patients (mean age 60±11 years, 60% women) of whom 990 (48.5%) had a CAC score of 0 were included in the analysis. Symptom characteristics were: 38% non-anginal chest pain, 30% atypical angina, 19% dyspnea, and 13% typical chest pain. Overall, the prevalence of obstructive CAD was 12.8% (n=262). Pretest probability of obstructive CAD increased progressively with age, from 6.0% in patients young than 50 years to 20.7% in those 70 years or older. Contrariwise, the prevalence of patients with a CAC score = 0 decreased from 77% in patients younger than 50 years, to 26% in those who where 70 years or older. The added diagnostic value of a CAC score = 0 was lower in younger patients, with negative likelihood ratios ranging from 0.36 (64% decrease in the likelihood of CAD) in patients younger than 50 years, to 0.09 and 0.10 (∼90% decrease in the likelihood of CAD) in those aged 60–69 years and 70 years or older, respectively – Figure 1. Despite this, the prevalence of obstructive CAD among patients with a CAC score = 0 was low across all age groups: 2.4% (i.e., NPV = 97.6%) in those younger than 50 years, 3.0% (NPV = 97.0%) among those aged 50–59 years, 1.5% (NPV = 98.5%) in patients between 60 and 69 years, and 2.0% (NPV = 98.0%) among those 70 years or older. Conclusions In a cohort of symptomatic patients undergoing CCTA for suspected CAD, the added diagnostic value of a CAC score of zero decreases significantly at younger ages. However, this “diminishing return” of CAC in younger patients if offset by their lower pretest probabilities, yielding high negative predictive values independently of age. Funding Acknowledgement Type of funding sources: None.

This scientific statement reviews the scientific data for cardiac computed tomography (CT) related to imaging of coronary artery disease (CAD) and atherosclerosis. Cardiac CT is a CT imaging technique that accounts for cardiac motion, typically through the use of ECG gating. The utility and limitations of generations of cardiac CT systems are reviewed in this statement with emphasis on CT measurement of CAD and coronary artery calcified plaque (CACP) and noncalcified plaque. Successive generations of CT technology have been applied to cardiac imaging beginning in the early 1980s with conventional CT, electron beam CT (EBCT) in 1987, and multidetector CT (MDCT) in 1999. Compared with other imaging modalities, cardiac CT has undergone an accelerated …

Background The North American 2021 Chest Pain Guidelines recommend not testing stable patients with low pretest likelihood of obstructive coronary artery disease (CAD), defined as pretest probability <15% using contemporary models (Class I recommendation). In selected cases among this subset of patients, coronary artery calcium (CAC) score is considered a “reasonable first-line test” (Class IIa). Despite some supporting evidence, the clinical implications of a widespread adoption of these recommendations remain unclear. The purpose of this study was to assess the results of three different testing strategies for patients with pretest probability <15%: A) defer testing; B) perform CAC score and withhold further testing if = 0, and proceed to coronary CT angiography (CCTA) if >0; C) perform CCTA in all. Methods We conducted a two-center cross-sectional study assessing symptomatic patients with suspected CAD who underwent CAC score and CCTA. Patients with known CAD, suspected acute coronary syndrome, or symptoms other than chest pain or dyspnea were excluded. Pretest probability of obstructive CAD was calculated based on age, sex and symptom typicality. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. Results A total of 2259 patients were screened, of which 1385 (61.3%) had pretest probability <15% and were included in the analysis (mean age 57±11 years, 79% women). Symptom characteristics were: 48% non-anginal chest pain, 26% atypical angina, 21% dyspnea, and 5% typical chest pain. Overall, the prevalence of obstructive CAD was 10.3% (n=142). In the 786 patients (56.6%) with a CAC score of 0, 8.5% (n=67) had some degree of CAD [1.9% (n=15) obstructive, and 6.6% (n=52) nonobstructive]. Among those with CAC >0 (n=599), 21.2% (n=127) had obstructive CAD. The results that would be reached with each of the 3 diagnostic strategies are presented in Figure 1. The number of patients needed to scan with strategy B (CAC as gatekeeper) vs. A (no testing) to identify one patient with obstructive CAD was 11, whereas the number needed to scan with strategy C (CCTA for all) vs. strategy B was 91. Conclusions Not testing patients with suspected CAD and pretest likelihood <15% would lead to missing obstructive CAD in 1 out of 10 patients. Using CAC as a gatekeeper in this subgroup would decrease the use of CCTA by more than 50%, at the cost of missing obstructive CAD in 1 out of 100 patients. These findings may be used to inform decisions on testing, which will ultimately depend on how much diagnostic uncertainty and missed diagnoses patients and their physicians are willing to accept. Funding Acknowledgement Type of funding sources: None.

Objectives:The purpose of this study is to assess the diagnostic performance of coronary artery calcium score (CACS), computed tomography coronary angiography (CTCA), and the prevalence of coronary artery disease (CAD) as etiology of heart failure (HF) in the Middle Eastern population.Background:CTCA has several advantages compared to invasive coronary angiography (ICA). However, studies on the diagnostic accuracy of CTCA and CACS in detecting the prevalence of CAD in patients with newly diagnosed HF are lacking in the Middle East.Methods:This study included 204 patients with symptoms of HF and ejection fraction (EF) of <50% by echocardiography who underwent CTCA for diagnosis of CAD within 3 months. The exclusion criteria were defined as patients with a history of CAD, percutaneous coronary intervention, or coronary artery bypass grafting. All patients with obstructive CAD based on CTCA were referred for ICA. In addition, 30 patients with normal CTCA also underwent ICA for verification.Results:The mean age was 48 ± 13 years, 69% (n = 141) were male and 31% (n = 73) were female, mean left ventricular EF was 31% ± 9%, and mean CACS was 58 ± 120. Based on the CTCA results, 169 patients had normal or nonobstructive CAD, whereas 35 patients had obstructive CAD. ICA was performed in all 35 patients with obstructive CAD; 30 of them were confirmed as having abnormal ICA, and only 5 had nonobstructive CAD. In addition, 30 patients with normal CTCA underwent ICA testing and were confirmed as having normal ICA. The CTCA had 100% sensitivity, 84% specificity, 86% positive predictive value, and 100% negative predictive value. Of the total population, 30 (15%) who were documented as having obstructive CAD were classified as CAD HF based on ICA. The remaining 174 (85%) patients were classified as having no CAD HF based on normal CTCA and/or ICA. The prevalence of CAD HF based on ICA was 15%. There was a strong correlation between CACS and both CTCA and ICA, with P = 0.001 and 0.0048, respectively.Conclusion:In patients with newly diagnosed HF, CACS and CTCA had a 100% sensitivity and negative value as well as overall excellent diagnostic accuracy. CACS = 0 excluded CAD as the etiology of HF with correlation between CACS groups and both CTCA and ICA. The prevalence of CAD as etiology of HF in the study population was 15%.

Implications of three different testing strategies in the diagnostic approach to patients with stable chest pain and low pretest probability of obstructive coronary artery disease

In recent decades, there has been an appropriate focus on ensuring gender equity in the quantity and quality of evidence to guide female-specific, optimal management strategies for suspected and known ischemic heart disease (IHD). The evolving evidence supports a multifactorial pathophysiology of coronary atherosclerosis that includes obstructive coronary artery disease (CAD) and dysfunction of the coronary microvasculature and endothelium, and therefore, the term IHD best encompasses this varied pathophysiology in women. An overwhelming body of evidence has documented undertreatment and undertesting of women, leading to higher case fatality rates and increased morbid complications among women.1–3 Accordingly, to increase our knowledge base, women were given the status of a priority population, which resulted in federal policy to include proportional representation of females in clinical trials and registries.4 The past decade provided abundant evidence to guide clinical decision making regarding diagnostic testing for suspected IHD. In 2005, the American Heart Association (AHA) published an evidence synthesis on the use of CAD imaging for the evaluation of symptomatic women with suspected myocardial ischemia.5 Numerous reports have since provided additional high-quality evidence, including data on coronary computed tomographic angiography (CCTA) and cardiac magnetic resonance imaging (CMR), which in 2005 were considered research techniques.5 The present statement provides an update to the 2005 document and synthesizes contemporary evidence on appropriate symptomatic female candidates for diagnostic testing, as well as sex-specific data on the diagnostic and prognostic accuracy for exercise treadmill testing (ETT) with electrocardiography, stress echocardiography, stress myocardial perfusion imaging (MPI) with single-photon emission computed tomography (SPECT) or positron emission tomography (PET), stress CMR, and CCTA.5 Within this document, quality evidence is synthesized, and important gaps in knowledge about the assessment of IHD risk in women are identified. The 2005 document included sections on the evaluation of asymptomatic …

Non-Invasive Imaging in Coronary Syndromes: Recommendations of The European Association of Cardiovascular Imaging and the American Society of Echocardiography, in Collaboration with The American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance

Funding Acknowledgements Type of funding sources: None. Introduction Current guidelines recommend not to routinely test patients with chest pain and low pretest probability (PTP &amp;lt;15%) of obstructive coronary artery disease (CAD) but envisage the use of risk modifiers such as coronary artery calcium score (CACS) to refine patient selection for testing. The aim of this study was to assess the cost-effectiveness (CE) of three different testing strategies in the approach to symptomatic patients with low PTP of obstructive CAD: A) not test; B) perform CACS, withholding testing if = 0 and proceeding to coronary CT angiography (CCTA) if &amp;gt; 0; and C) perform CCTA in all cases, without prior CACS. Methods We developed a CE model using data from a two-centre study of 1385 patients with non-acute chest pain and PTP &amp;lt;15% who underwent CACS immediately followed by CCTA. Key input data included the proportion of patients with obstructive CAD on CCTA (10.3%), the proportion with CACS=0 (57%), and the negative predictive value of CACS for obstructive CAD on CCTA (98.9%), which was considered the gold standard for this simulation. The CE of each strategy was defined as the cost per correct diagnosis. Direct costs were calculated using the price list from the Portuguese National Health Service. Indirect costs, including incidental findings, were estimated according to the literature. The cost attributable to a false-negative was set at 3 times the cost of a false-positive, as customary. Results Not testing would correctly classify 89.7% of cases, and would cost €121.433 per 1000 patients, due to the cost imputed to false negatives. Using CACS as a gatekeeper for CCTA would correctly diagnose 98.9% of cases, and cost €247.116 per 1000 patients. Employing CCTA as first-line test would correctly classify all patients, at a cost of €271.007 for 1000 diagnosed patients. Overall, the added cost for an additional correct diagnosis was €1.366 for CACS±CCTA strategy vs. no testing, and €2.172 for CCTA vs. CACS±CCTA. The corresponding cost-effectiveness thresholds (CET) were €943–€3.450 for men; and €1.527–€1.972 for women (Table 1). Conclusions Not testing patients with low PTP of obstructive CAD should be disfavoured unless the CET is below €1.366 per correct diagnosis. First-line CCTA yields the most correct diagnoses and is cost-effective above CET over €2.172 per additional correct diagnosis. Using CACS as a gatekeeper for further testing is cost-effective between these thresholds, which are wider for men than for women. These findings may inform decisions on testing, but the most suitable strategy will ultimately depend on the costs and amount of missed diagnoses stakeholders are willing to accept.

Coronary artery calcium (CAC) scoring by computed tomography (CT) has been the subject of intense interest and critical scrutiny since it was first reported as a clinical tool in 1990.1 With improvements in study design, greater availability of coronary CT scanners, and increased attention to the posttest prognosis of patient samples and asymptomatic individuals who have undergone coronary CT, CAC measurement is now considered a potentially useful test for improving coronary risk assessment in selected intermediate-risk asymptomatic patients in whom high CAC scores signify increased cardiovascular risk beyond that predicted by conventional cardiovascular risk factors alone.2 Article p 1693 At the other end of the spectrum, does a very low CAC score signify very low risk? An American Heart Association writing group3 stated that a CAC score of zero (CAC=0; ie, no calcified plaque detected) indicated 1) that the presence of atherosclerotic plaque, including unstable or vulnerable plaque, was highly unlikely; 2) that the presence of significant luminal obstructive disease was highly unlikely (negative predictive value on the order of 95% to 99%); and 3) that the risk of a cardiovascular event in the next 2 to 5 years was quite low (0.1 per 100 person-years). In addition, at least 1 early study suggested that CAC=0 might be useful in the emergency room setting as a tool to rule out myocardial ischemia in symptomatic patients.4 A recent review article5 suggested the same conclusions. However, as pointed out by a different …

Letter in response to Andrea K.Y. Lee et al. “Normalcy rate of computed tomographic coronary angiography”

Influence of Age on the Diagnostic Value of Coronary Artery Calcium Score for Ruling Out Obstructive Coronary Disease in Symptomatic Patients

We sought to explore the relationship between pericardial fat volume (PFV) and both coronary atherosclerosis (CA) extent and severity using coronary artery calcium score (CAC), computed tomography coronary angiography (CTCA), and invasive coronary angiography in patients at high to intermediate likelihood of coronary artery disease (CAD). Patients clinically referred to invasive angiography who underwent CTCA and CAC within 1 month before the procedure comprised the study population. PFV, CAC, atherosclerotic burden indexes [segment involvement score (SIS); segment stenosis score; three-vessel plaque; and any left main plaque], and the invasive angiography-derived CAD index were evaluated independently. A total of 75 patients were included in the study. PFV did not differ between patients with or without obstructive (stenosis >70%) CAD defined by invasive angiography (86.4 ± 31.7 vs. 77.1 ± 42.8 cm3, P = 0.34), although patients with obstructive CAD had significantly higher CAC scores [636.0 (IQR 229.5-1101.0) vs. 206.0 (IQR 0.0-675), P < 0.0001] than patients without obstructive CAD. Patients with extensive CA (SIS > 5) had significantly larger PFV (89.9 ± 33.9 vs. 58.7 ± 33.2 cm3, P = 0.003) than patients with non-extensive CA. Significant correlations were found between PFV and CAC (r = 0.49, P < 0.0001), and SIS (r = 0.46, P < 0.0001), whereas very weak correlations were observed between PFV and the CAD index (r = 0.27, P = 0.02), and between PFV and the body mass index (r = 0.33, P = 0.004). The main finding of the present study was the identification of PFV as more closely related to atherosclerotic plaque burden rather than to lesion severity in patients referred to invasive coronary angiography.

Coronary artery calcium score as a gatekeeper for further testing in patients with low pretest probability of obstructive coronary artery disease: A cost-effectiveness analysis

Cardiac computed tomography perfusion (CTP) using stress testing is an emerging application in the field of cardiac computed tomography. We evaluated patients with acute chest pain (CP) in the emergency department (ED) with evidence of obstructive coronary artery disease (CAD), defined as >70% stenosis on coronary computed tomography angiography (CCTA) and confirmed by invasive coronary angiography (ICA), to evaluate the applicability of resting CTP in the acute CP setting. From January to December 2013, 183 low-intermediate risk symptomatic patients with negative cardiac biomarkers and no known CAD underwent a rapid CCTA protocol in the ED. Of these, 4 patients (1.4%) had obstructive CAD (≥70% stenosis) on CCTA confirmed by ICA. All 183 CCTA studies were evaluated retrospectively with CTP software by a transmural perfusion ratio (TPR) method with a superimposed 17-segment model. A TPR value <0.99 was considered abnormal based on previously published data. A total of four patients were included in this pilot analysis. The duration from resolution of CP to performance of CCTA ranged from 1.6 to 5.0 hours. Three patients underwent revascularization, two with percutaneous coronary intervention (PCI) and one with coronary artery bypass grafting. The fourth patient was managed with aggressive medical therapy. Two patients had multivessel obstructive CAD and two patients had single-vessel CAD. The first patient underwent CCTA 5 hours after resolution of CP symptoms. CCTA demonstrated noncalcified obstructive CAD in the mid-LAD and mid-right coronary artery. ICA showed good correlation by quantitative coronary assessment (QCA) in both vessels and the patient underwent PCI. CTP analysis demonstrated perfusion defects in the LAD and right coronary artery territories. The second patient underwent CCTA 1.6 hours after resolution of CP symptoms with findings of obstructive ostial left main CAD. ICA confirmed obstructive left main CAD by QCA and intravascular ultrasound. The patient underwent revascularization with coronary artery bypass grafting. CTP demonstrated perfusion defects in the anterior and lateral wall segments. The third patient was evaluated for CP in the ED with CCTA demonstrating single-vessel CAD 10 hours after resolution of symptoms with findings of a noncalcified obstructive stenosis in the mid-LAD. The patient subsequently underwent ICA demonstrating good correlation to the CCTA findings in the LAD by QCA. CTP analysis revealed perfusion defects in LAD territory. He was successful treated with PCI. The final patient underwent CCTA 5.4 hours following resolution of CP with the finding of an intermediate partially calcified stenosis in the distal LAD. ICA was performed, with fractional flow reserve demonstrating a hemodynamically insignificant distal LAD at 0.86. CTP detected a perfusion defect in the LAD territory. When positive, rest CTP may have value in the risk stratification of patients presenting to the ED with nontraumatic acute CP.