Intermediate Pretest Probability Research Articles

Clinical quantitative coronary artery stenosis and coronary atherosclerosis imaging: a Consensus Statement from the Quantitative Cardiovascular Imaging Study Group.

The detection and characterization of coronary artery stenosis and atherosclerosis using imaging tools are key for clinical decision-making in patients with known or suspected coronary artery disease. In this regard, imaging-based quantification can be improved by choosing the most appropriate imaging modality for diagnosis, treatment and procedural planning. In this Consensus Statement, we provide clinical consensus recommendations on the optimal use of different imaging techniques in various patient populations and describe the advances in imaging technology. Clinical consensus recommendations on the appropriateness of each imaging technique for direct coronary artery visualization were derived through a three-step, real-time Delphi process that took place before, during and after the Second International Quantitative Cardiovascular Imaging Meeting in September 2022. According to the Delphi survey answers, CT is the method of choice to rule out obstructive stenosis in patients with an intermediate pre-test probability of coronary artery disease and enables quantitative assessment of coronary plaque with respect to dimensions, composition, location and related risk of future cardiovascular events, whereas MRI facilitates the visualization of coronary plaque and can be used in experienced centres as a radiation-free, second-line option for non-invasive coronary angiography. PET has the greatest potential for quantifying inflammation in coronary plaque but SPECT currently has a limited role in clinical coronary artery stenosis and atherosclerosis imaging. Invasive coronary angiography is the reference standard for stenosis assessment but cannot characterize coronary plaques. Finally, intravascular ultrasonography and optical coherence tomography are the most important invasive imaging modalities for the identification of plaques at high risk of rupture. The recommendations made in this Consensus Statement will help clinicians to choose the most appropriate imaging modality on the basis of the specific clinical scenario, individual patient characteristics and the availability of each imaging modality.

CT-derived fractional flow reserve for prediction of major adverse cardiovascular events in diabetic patients

ObjectivesTo investigate the prognostic value of computed tomography fractional flow reserve (CT-FFR) in patients with diabetes and to establish a risk stratification model for major adverse cardiac event (MACE).MethodsDiabetic patients with intermediate pre-test probability of coronary artery disease were prospectively enrolled. All patients were referred for coronary computed tomography angiography and followed up for at least 2 years. In the training cohort comprising of 957 patients, two models were developed: model1 with the inclusion of clinical and conventional imaging parameters, model2 incorporating the above parameters + CT-FFR. An internal validation cohort comprising 411 patients and an independent external test cohort of 429 patients were used to validate the proposed models.Results1797 patients (mean age: 61.0 ± 7.0 years, 1031 males) were finally included in the present study. MACE occurred in 7.18% (129/1797) of the current cohort during follow- up. Multivariate Cox regression analysis revealed that CT-FFR ≤ 0.80 (hazard ratio [HR] = 4.534, p < 0.001), HbA1c (HR = 1.142, p = 0.015) and low attenuation plaque (LAP) (HR = 3.973, p = 0.041) were the independent predictors for MACE. In the training cohort, the Log-likelihood test showed statistical significance between model1 and model2 (p < 0.001). The C-index of model2 was significantly larger than that of model1 (C-index = 0.82 [0.77–0.87] vs. 0.80 [0.75–0.85], p = 0.021). Similar findings were found in internal validation and external test cohorts.ConclusionCT-FFR was a strong independent predictor for MACE in diabetic cohort. The model incorporating CT-FFR, LAP and HbA1c yielded excellent performance in predicting MACE.

Incidental Coronary Artery Disease on Routine CT Coronary Angiography –An evidence-based approach

Atherosclerotic coronary artery disease is the leading cause of high morbidity and mortality across the globe [1]. Coronary CT angiography has emerged as a highly accurate non-invasive diagnostic modality for the diagnosis of atherosclerotic coronary artery disease [2]. Coronary CT angiography should be considered as an alternative to stress imaging technique for ruling out atherosclerotic coronary artery disease in patients with the lower range of intermediate pre-test probability for atherosclerotic stable coronary artery disease. However, coronary CT angiography is not recommended as a screening test in asymptomatic individuals without clinical suspicion of coronary artery disease. CT Coronary angiography has been performed routinely before many of the cardiac and non-cardiac procedures like TAVI, atrial fibrillation ablation prior to the organ transplantation. Many a times, advised by Family Physician or patients themselves for a routine screening for atherosclerotic coronary artery disease undergo CT coronary angiography. When incidental atherosclerotic coronary artery disease is found in such patients who do not have any typical or atypical symptom suggestive of coronary artery disease then question arises how to approach this patient as far as the risk estimation for future adverse cardiovascular event and prognostication is concerned. It also becomes imperative to decide the line of management for this patient. To answer these two pertinent questions, we need to understand the behavior and natural history of atherosclerosis &amp; performance of CT coronary angiography in diagnosis and in predicting the prognosis of atherosclerotic disease.

Clinical Application of Myocardial Perfusion SPECT in Patients with Suspected or Known Coronary Artery Disease. What Role in the Multimodality Imaging Era?

Myocardial perfusion single photon emission computed tomography (SPECT) is widely used in assessing coronary artery disease (CAD) owing to its proven efficacy in extensive clinical experience. Like other functional tests, myocardial SPECT is recommended for the diagnosis of obstructive CAD, risk stratification assessment, and treatment decision making. Besides quantifying left ventricular volume, global and regional function by electrocardiography (ECG)-gated acquisition, myocardial SPECT can identify myocardial ischemia, scars, stunning, and viable hibernating myocardium. It provides comprehensive functional data across the spectrum of CAD and a cost-effective strategy in patients with intermediate pre-test probability of CAD or with a history of ischemic cardiomyopathy. With ongoing advances in cardiovascular prevention and risk factor management many patients referred for testing now have a low-to-intermediate probability of CAD. Besides, CAD has become a chronic condition resulting from novel therapeutic strategies. Against this background, approaches combining anatomical and functional tests in sequence or simultaneously include coronary artery calcium score integrated with perfusion imaging or fusion SPECT/coronary computed tomography angiography (CCTA). In this review we summarize current indications for myocardial perfusion SPECT and integration of SPECT with other imaging techniques to improve diagnostic performance, patient management, and outcome prediction in CAD.

Accuracy of stress perfusion cardiac magnetic resonance imaging in a district hospital.

The European Society of Cardiology has published updated guidelines regarding pathways for diagnosis and management of obstructive coronary artery disease (CAD). Non-invasive functional assessment, for example, by stress perfusion cardiac magnetic resonance (stress pCMR) is recommended in patients with intermediate pretest probability of disease. Previous pCMR studies were mainly performed in high volume university hospitals with experienced radiologists or cardiologists interpreting the images. The aim of the present study was to evaluate the feasibility of establishing a stress pCMR imaging service in a district hospital. One hundred and thirteen patients with intermediate pretest probability of CAD referred for single-photon emission computed tomography (SPECT) at the regional hospital also underwent adenosine stress pCMR locally. The diagnostic analysis was compared to that of an experienced cardiac magnetic resonance (CMR) center serving as a reference. Inter-rater agreement between local readers and the reference reader was substantial to perfect for late gadolinium enhancement (LGE) (weighted kappa = 0.76 and 0.82), but only fair to moderate for pCMR (k = 0.34 and 0.51). No improvement in agreement between reference reader and local reader during the study was demonstrated. CMR is feasible in patients with intermediate pretest probability of obstructive CAD in the setting of a district hospital. However, as opposed to infarct detection with LGE, the interpretation of stress pCMR was more challenging. To establish this method, we suggest obtaining experience in close collaboration with a reference CMR center.

Radiomics in Cardiac Computed Tomography.

In recent years, there has been an increasing recognition of coronary computed tomographic angiography (CCTA) and gated non-contrast cardiac CT in the workup of coronary artery disease in patients with low and intermediate pretest probability, through the readjustment guidelines by medical societies. However, in routine clinical practice, these CT data sets are usually evaluated dominantly regarding relevant coronary artery stenosis and calcification. The implementation of radiomics analysis, which provides visually elusive quantitative information from digital images, has the potential to open a new era for cardiac CT that goes far beyond mere stenosis or calcification grade estimation. This review offers an overview of the results obtained from radiomics analyses in cardiac CT, including the evaluation of coronary plaques, pericoronary adipose tissue, and the myocardium itself. It also highlights the advantages and disadvantages of use in routine clinical practice.

How did the COVID-19 pandemic affect the referral patterns for SPECT myocardial perfusion? A single center experience.

We evaluated the impact of the COVID-19 pandemic on the number of referrals for SPECT myocardial perfusion imaging (SPECT-MPI) as well as changes in the clinical and imaging characteristics. We respectively reviewed 1042 SPECT-MPI cases performed in a 4-month period during the COVID-19 pandemic (PAN; n=423) and compared their findings with those acquired in the same months before the pandemic (PRE; n=619). The number of stress SPECT-MPI studies performed during the PAN period significantly dropped compared to the number of studies carried out in the PRE period (p = 0.014). In the PRE period, the rates of patients presenting with non-anginal, atypical and typical chest pain were 31%, 25% and 19%, respectively. The figures significantly changed in the PAN period to 19%, 42%, and 11%, respectively (all p-values <0.001). Regarding the pretest probability of coronary artery disease (CAD), a significant decrease and increase were noticed in patients with high and intermediate pretest probability, respectively (PRE: 18% and 55%, PAN: 6% and 65%, p <0.001 and 0.008, respectively). Neither the rates of myocardial ischemia nor infarction differed significantly in the PRE vs. PAN study periods. The number of referrals dropped significantly in the PAN era. While the proportion of patients with intermediate risk for CAD being referred for SPECT-MPI increased, those with high pretest probability were less frequently referred. Image parameters were mostly comparable between the study groups in the PRE and PAN periods.

Coronary artery calcification – distribution, extent and 1-year outcomes in patients with low to intermediate pre-test probability of coronary artery disease

Coronary artery calcium (CAC) is an established marker to predict major cardiovascular events (MACE), and has incremental value over traditional risk factors (CVRF). CAC is widely available, easily reproducible, and used in nearly all coronary computed tomography angiography (CCTA) assessment protocols for coronary artery disease (CAD). The distribution and extent of CAC, and its prognostic implications in local Malaysian patients with low to intermediate pre-test probability (LI-PTP) of CAD had not been established.

Coronary Computed Tomography Angiography as part of initial strategy, in assessment of patients with chest pain – clinical experience and 1 year prognosis

Coronary computed tomography angiography (CCTA) has been showed to have high specificity and sensitivity for detecting coronary artery disease (CAD). In Malaysia, national guidelines state that CCTA may be used in low- to intermediate pre-test probability (LI-PTP) of CAD, who have an equivocal functional test result, and who are asymptomatic or mildly symptomatic with good exercise capacity. Recent evidence suggested “CCTA-first” strategy in the evaluation of a patient with chest pain could provide prognostic benefits.

Computed tomography to replace invasive coronary angiography? The DISCHARGE trial.

Ongoing advancements of coronary computed tomographic angiography (CTA) continue to challenge the role of invasive coronary angiography (ICA) as the gold standard for the evaluation of coronary artery disease (CAD). To investigate the comparative effectiveness of ICA when compared with CTA as an initial diagnostic imaging strategy the DISCHARGE Trial enrolled 3561 patients with stable chest pain and an intermediate pre-test probability of obstructive CAD. The study showed no difference between CTA and ICA in the incidence of the primary composite outcome of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke during 3.5 years of follow up. As with many trials that advance a field, this trial raises several additional questions of interest that will be discussed. Furthermore, recent studies focused on the discrepancies of CTA vs. ICA indicate that the status of CTA remains unchanged in its ability to rule out disease but at present cannot be considered a substitute for ICA when coronary lesions are documented. Thus, a change in clinical practice patterns likely requires evidence from clinical studies demonstrating equivalence of CT to ICA for guiding medical management. Developments, however, are swift, and CT technology is catching up on its invasive counterpart.

Abstract 11380: Exercise Induced ST Segment Elevation Caused by Coronary Vasospasm

Case Presentation: A 52-year-old male with no known medical history was seen in the cardiology clinic for occasional pressure-like chest pain on exertion. Due to an intermediate pretest probability of CAD, ischemic workup with a nuclear perfusion exercise stress test was planned. Patient achieved maximum predicted heart rate after 12 minutes of exercising, with no anginal symptoms, ST segment changes or arrhythmias during the entire period. However, 3 minutes into the recovery phase, he developed chest pain and diaphoresis, with EKG now showing 7mm ST elevations in the inferior leads and BP falling to 77/56 mmHg. STEMI code was called, and patient was emergently taken to the cardiac cath lab for coronary angiogram and possible PCI. Angiogram found the coronary arteries to be non-obstructive but revealed vessels possibly having vasospasm. Intra coronary nitroglycerin was given with no further PCI. The patient’s symptoms subsided after the angiogram, and he remained asymptomatic thereupon and was eventually discharged on Verapamil and nitrate therapy. Discussion: Typically, vasospastic angina occurs at rest. Exercise induced and post-exercise recovery phase ST segment elevation on EKG is associated with severe atherosclerotic disease with significant coronary obstruction. However, exercise induced ST elevations in the post exercise recovery phase caused by non-obstructive, vasospastic coronary arteries, as seen in this patient, is a rare occurrence. The vasospasm is hypothesized to be due to coronary vascular smooth muscle hyperactivity and endothelial cell dysfunction. Treatment is usually with calcium channel blockers, nitrates and lifestyle modification such as smoking cessation and alcohol restriction. This case illustrates the importance of identifying the etiology of the angina, noting that post exercise ST segment elevations are not always associated with coronary vessel obstruction and vasospasm should be considered as a possible etiology.

Abstract 12668: Coronary CTA Finding of Libman Sacks Endocarditis Presenting as Chest Pain

Case Presentation: A 65-year-old female with a history of hypertension, hyperlipidemia, microscopic colitis, fibromyalgia, left hand dupuytren's contractures, Grave’s disease and seronegative rheumatoid arthritis presented to the outpatient office for evaluation of right sided stabbing and heavy chest pain. ECG showed sinus bradycardia without any ST segment changes. She had an Echo and exercise stress Echo prior to her office visit. Her echo showed normal left ventricular size and systolic function with no regional wall motion abnormality and thickened aortic valve with mild aortic stenosis (peak transvalvular gradient 9.9 mmHg and mean 5.9 mmHg). Her stress echo was negative for ischemia although submaximal (exercised for 6.05 minutes, achieving only 75% MPHR, and double product of 18720). It was then decided to pursue a coronary CTA given the suboptimal nature of her stress testing and intermediate pretest probability of coronary artery disease. This revealed mild-to-moderate non-obstructive CAD and thickening of her left coronary cusp. The thickening was concerning for Libman-Sacks endocarditis vs native aortic valve thrombosis (see figure). Her Antinuclear antibody (ANA) titers was 1280. She was started on therapeutic anticoagulation with a plan for repeat imaging in six months. Discussion: Coronary cusp thickening represents a variety of differentials and has comparable structural and clinical qualities. Atypical chest pain in our patient led to the incidental finding of left coronary cusp thickening. In the presence of elevated ANA and her autoimmune disorder, Libman-Sacks endocarditis vs native aortic valve thrombosis was suspected hence the initiation of anticoagulation. Both have a propensity for fatal outcomes including, but not limited to myocardial infarction, embolic events, cardiogenic shock, or death. Follow-up imaging with a resolution of thrombus would confirm the diagnosis of native aortic valve thrombus.

Comparative effectiveness of initial computed tomography and invasive coronary angiography in women and men with stable chest pain and suspected coronary artery disease: multicentre randomised trial

ObjectiveTo assess the comparative effectiveness of computed tomography and invasive coronary angiography in women and men with stable chest pain suspected to be caused by coronary artery disease.DesignProspective, multicentre, randomised...

Correlation between coronary artery disease and coronary microvascular dysfunction symptoms and cardiac SPECT results in Latvian women patients

Abstract Introduction The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation. Women patients with intermediate or high pre-test probability for coronary artery disease – even asymptomatic or with non-informative exercise test should be referred for further focused diagnostics. Myocardial perfusion imaging with single photon emission computed tomography (SPECT) is one of the most performed non-invasive cardiac imaging tests to diagnose CAD or coronary microvascular dysfunction (CMVD). Purpose To evaluate the correlation between various CAD symptoms and cardiac SPECT results in women patients undergoing examination due to diagnosis of CAD or CMVD. Methods During the period from 2018 till 2021 we performed cardiac SPECT for women patients with intermediate or high pre-test probability or non-informative exercise test. Patients were divided into 2 groups: normal myocardial perfusion or true myocardial perfusion defect, defined as area of ischemia ≥10% of the left ventricle myocardium mass. According to the clinical symptoms patients were categorized in “asymptomatic”, “atypical symptom” and “patients with chest pain” group. The presence of CMVD and CAD in each group was determined by invasive coronary angiography or computed tomography angiography. Results In 4 years, SPECT was performed in 726 women patients. The most common presented symptoms were: chest pain (n=487, 67.1%), dyspnea (n=323, 44.5%), tachycardia and palpitations (n=117, 16.1%), fatigue (n=129, 17.8%), headache (n=28, 3.86%) and excessive sweating (n=15, 2.1%). 104 (14.3%) patients were asymptomatic, 487 (67.1%) with chest pain and 135 (18.6%) with atypical symptoms. True myocardial perfusion defect was detected in 125 patients (17.2%). The obstructive CAD was found in 32 cases (25.6%; 4.4% of all SPECTs). The CMVD was diagnosed in 68 women (54.4%; 9.4% of all SPECTs). In asymptomatic patient group obstructive CAD was diagnosed in 5 (4.8%) cases, in chest pain group – 11 (2.3%) cases and in atypical symptom group – 16 (11.9%) patients (p&amp;lt;0.001). None of asymptomatic women had CMVD. The CMVD was detected in 53 (42.4%; 7.3% of all) cases in chest pain group and in 14 (11.3%; 1.9% of all) patients in atypical symptom group (p=0.006). Conclusion Women patients with typical chest pain were more likely to have CMVD, but with atypical symptoms – CAD. Since women are in a very high cardiovascular risk group in Latvia, the cardiac SPECT is highly recommended for detection of CAD and CMVD, especially in patients with atypical symptoms. Funding Acknowledgement Type of funding sources: None.

Sex Differences in Computed Tomographic Angiography in Patients with Low and Intermediate Pretest Probability of Coronary Artery Disease

Background: Multi-slice computed tomography (MSCT) coronary angiography has become one of the hot spots in cardiovascular imaging technology. Many of the sex-based research have shown that women have different pathogenesis, clinical presentation and complication related to coronary artery disease (CAD) as compared to the males. The aim of this study investigated the relationship between gender and coronary artery calcium (CAC) in patients with chest discomfort with low and intermediate pretest probability of CAD who underwent Coronary computed tomography angiography (CCTA) and referrals by gender for subsequent invasive coronary angiography and revascularization.&#x0D; Methods: This prospective cohort study included 200 patients suspected to have coronary artery disease, negative or equivocal stress tests, with no prior known coronary artery disease (CAD), intermediate pretest probability for CAD according to the scoring method of (15-65 points), and Low likelihood for CAD (&lt; 15 points). Patients were divided into two groups according to gender and were followed up. All patients underwent Full history taking, full clinical examination, routine laboratory investigation, resting and exercise ECG, echocardiography, CT coronary angiography and invasive Coronary angiography.&#x0D; Results: Patients with mild calcium score level were significantly higher in no CAD group than CAD group (p &lt;0.001) and patients with high calcium score were significantly higher in CAD group than no CAD group (p &lt;0.001). In univariate regression analysis age, typical chest pain, obesity, coronary Ca score, and hyperlipidemia are independent predictors for CAD in females. In multivariate regression analysis, age, typical chest pain, hypertension, and coronary Ca score are predictors for CAD in males. Coronary calcium score is a good predicator for CAD (AUC =0.901, 95% CI =0.851-0.938, p value &lt;0.001). At cut off value &gt; 101, it has 70.97% sensitivity, 90.79% specificity, 92.6% PPV, and 65.7% NPV. Moreover, it is a good predicator for CAD in females (AUC =0.894, 95% CI =0.823 – 0.944, p value &lt;0.001). At cut off value &gt; 101, it has 60.71% sensitivity, 91.67% specificity, 87.2% PPV, and 71.4% NPV.&#x0D; Conclusions: In patients with chest discomfort with low and intermediate pretest probability of CAD who underwent CCTA and subsequent invasive coronary angiography and revascularization, female patients had lower age, hypertension, pretest probability score, calcium score, atypical angina, nonanginal chest pain and obstructive CAD but had higher BMI, typical angina than males’ group. In females, coronary calcium score is a good predicator for CAD. When its level exceeds 100, it has 60.71% sensitivity and 91.67% specificity. In addition, it was found that in females typical chest pain and coronary Ca score are predictors for CAD and in males, age, typical chest pain, hypertension, and coronary Ca score are predictors for CAD.

CLINICAL CHARACTERISTICS OF WOMEN REFERRED TO CARDIAC SPECT: WHEN AND WHO? DATA FROM LATVIAN CARDIAC SPECT REGISTRY

Objective: Population based cross-sectional study of cardiovascular risk (CVR) factors in Latvia from year 2009 till 2019 revealed that women in age 25 -74 are in a very high CVR group: 61% of women have dyslipidemia, more than 33% have arterial hypertension (AH) and 28% are overweight. The data indicates the necessity for focused diagnostics and early detection of cardiovascular disease. The aim of study was to define the clinical profile and risk factors for women with suspected coronary artery disease (CAD) reffered to cardiac single photon emission computed tomography (SPECT) in Latvia and to find out the correlation between nuclear test result and patient clinical presentation. Design and method: Cardiac SPECT was performed in a single centre from 2018 till 2021. The women patients were analyzed by risk factors and previous diagnosis of CAD. Exercise test was performed in all cases. Patients were divided into 2 groups: normal myocardial perfusion or true myocardial perfusion defect, defined as area of ischemia more than 10% of the left ventricle myocardium mass. Results: 726 SPECT data were analyzed. The mean age of women patients was 62.6 ± 10.6 years. More than half of the patients (n = 486,66.9%) were overweight (BMI&gt; 25.0 kg/m2) and 33.3%(n = 242) were obese (BMI&gt; 30.0 kg/m2). 87 (11.9%) women were current or ex-smokers. Dyslipidemia was present in in 614 (84.6%), AH in 535 (73.7%) and type 2 Diabetes mellitus (T2DM) in 60 (8.3%) patients. 104 (14.3%) patients were asymptomatic, but with intermediate to high pre-test probability for CAD. Known CAD was present in 298 (41.0%) patients. Exercise test was found positive in 306 (42.1%) patients and the test result was not always associated with ischaemia in SPECT (p = 0.063). True myocardial perfusion defect was detected in 125 patients (17.2%). Correlation was found between significant perfusion defect in SPECT and risk factors - AH (p = 0.013) and dyslipidemia (p = 0.029). Conclusions: The registry proves the high value of imaging with cardiac SPECT for diagnostics of CAD. Women patients with intermediate or high pre-test probability – even asymptomatic or with non informative exercise test should be reffered for cardiac SPECT.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

CT or Invasive Coronary Angiography in Stable Chest Pain

BackgroundIn the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain.MethodsWe conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris.ResultsAmong 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P=0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48).ConclusionsAmong patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy. (Funded by the European Union Seventh Framework Program and others; DISCHARGE ClinicalTrials.gov number, NCT02400229.)

Pretest probability of coronary artery disease as a factor for optimizing invasive diagnostics in routine clinical practice

According to the European Society of Cardiology guidelines, patients with chest pain requires the calculation of pretest probability (PTP) of coronary artery disease (CAD), followed by the identification of diagnostic tactics.Aim. To analyze the registry of patients with stable CAD in order to assess the frequency of PTP calculation, as well as the validity of diagnostic tactics choice depending on its level.Material and methods. The data of the registry of patients with stable CAD for the periods from 2012 to 2014 and from 2017 to 2019 were analyzed. We assessed the number of CAD patients, proportion of men, and distribution of patients depending on angina functional class. In addition, data on PTP calculation, as well as distribution of patients and diagnostic strategy selected depending on its value was analyzed. To assess differences (p) in pairwise comparisons, Student’s t-test was used. Differences were considered significant at p&lt;0,05. Statistical analysis was performed using Microsoft Office Excel 2010 (Microsoft, USA) and STATISTICA 6.0 (StatSoft Inc., USA).Results. In 2017-2019, the number of detected CAD cases and proportion of men increased. In both time periods, an insufficient level of calculating PTP of CAD remains. In patients with intermediate PTP, 15-85% of priority tactics are invasive interventions, and with high PTP, the percentage of invasive methods does not reach the proper level, which does not correspond to modern guidelines for the management of CAD patients and leads to misappropriation of funds and healthcare resources.Conclusion. According to medical records, PTP can be determined in less than half of patients. In CAD patients with intermediate PTP, non-invasive studies are not carried out in full, since coronary angiography is preferred. In patients with a high PTP, invasive diagnostics is insufficient.

The Diagnostic and Prognostic Value of Coronary Calcium Scoring inStable Chest Pain Patients: A Narrative Review.

Background Non-contrast computed tomography (CT) scanning allows for reliable coronary calcium score (CCS) calculation at a low radiation dose and has been well established as marker to assess the future risk of coronary artery disease (CAD) events in asymptomatic individuals. However, the diagnostic and prognostic value in symptomatic patients remains a matter of debate. This narrative review focuses on the available evidence for CCS in patients with stable chest pain complaints. Method PubMed, Embase, and Web of Science were searched for literature using search terms related to three overarching categories: CT, symptomatic chest pain patients, and coronary calcium. The search resulted in 42 articles fulfilling the inclusion and exclusion criteria: 27 articles (n = 38 137 patients) focused on diagnostic value and 23 articles (n = 44 683 patients) on prognostic value of CCS. Of these, 10 articles (n = 21 208 patients) focused on both the diagnostic and prognostic value of CCS. Results Between 22 and 10 037 patients were included in the studies on the diagnostic and prognostic value of CCS, including 43 % and 51 % patients with CCS 0. The most evidence is available for patients with a low and intermediate pre-test probability (PTP) of CAD. Overall, the prevalence of obstructive CAD (OCAD, defined as a luminal stenosis of ≥ 50 % in any of the coronary arteries) as determined with CT coronary angiography in CCS 0 patients, was 4.4 % (n = 703/16 074) with a range of 0–26 % in individual studies. The event rate for major adverse cardiac events (MACE) ranged from 0 % to 2.1 % during a follow-up of 1.6 to 6.8 years, resulting in a high negative predictive value for MACE between 98 % and 100 % in CCS 0 patients. At increasing CCS, the OCAD probability and MACE risk increased. OCAD was present in 58.3 % (n = 617/1058) of CCS > 400 patients with percentages ranging from 20 % to 94 % and MACE occurred in 16.7 % (n = 175/1048) of these patients with percentages ranging from 6.9 % to 50 %. Conclusion Accumulating evidence shows that OCAD is unlikely and the MACE risk is very low in symptomatic patients with CCS 0, especially in those with low and intermediate PTPs. This suggests a role of CCS as a gatekeeper for additional diagnostic testing. Increasing CCS is related to an increasing probability of OCAD and risk of cardiac events. Additional research is needed to assess the value of CCS in women and patient management in a primary healthcare setting. Key Points: A CCS of zero makes OCAD in patients at low-intermediate PTP unlikelyA CCS of zero is related to a very low risk of MACECategories of increasing CCS are related to increasing rates of OCAD and MACEFuture studies should focus on the diagnostic and prognostic value of CCS in symptomatic women and the role in primary care Citation Format Koopman MY, Willemsen RT, van der Harst P et al. The Diagnostic and Prognostic Value of Coronary Calcium Scoring in Stable Chest Pain Patients: A Narrative Review. Fortschr Röntgenstr 2022; 194: 257 – 265