Stable Chest Pain Patients Research Articles

Coronary Artery Disease and Major Adverse Cardiovascular Events in People With Hepatic Steatosis at Low Atherosclerotic Cardiovascular Disease Risk.

Hepatic steatosis (HS) and 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥ 7.5% are associated with increased risk for cardiovascular events. To assess underlying coronary artery disease (CAD) and major adverse cardiovascular event (MACE) among those with and without HS at different ASCVD risk. We evaluated stable chest pain patients receiving coronary computed tomography (CT) in the PROMISE trial. HS and CAD endpoints were defined on coronary CT. MACE was defined as unstable angina, non-fatal myocardial infarction, and all-cause death. Multivariable Cox regression, adjusting for CAD characteristics, assessed the association of HS with MACE for ASCVD < 7.5%. One thousand two hundred and four of 3702 (32.5%) patients were at ASCVD < 7.5% and 20.3% (244/1204) of them had HS. Individuals with HS were younger (54.3 ± 5.2 vs. 55.8 ± 5.2; p < 0.001), more often males (40.2% [98/244] vs. 27.1% [260/960]; p < 0.001), had more risk factors/person (2.06 ± 0.89 vs. 1.93 ± 0.91; p = 0.047). CAD characteristics were similar between HS vs. non-HS patients at ASCVD < 7.5% and ASCVD ≥ 7.5% (all p > 0.05). Patients with HS had greater MACE rate compared to non-HS patients (ASCVD < 7.5%: 3.75%[9/244] vs. 1.5% [14/960]; p = 0.027 and ASCVD ≥ 7.5%: 4.7% [33/696] vs. 3.1% [56/1802]; p = 0.043). In patients without HS, MACE rate was higher in the ASCVD ≥ 7.5% vs. < 7.5% (3.1% [56/1802] vs. 1.5% [14/960]; p = 0.011). In patients with HS, MACE rates were not significantly different between ASCVD ≥ 7.5% vs. < 7.5% (4.7% [33/696] vs. 3.7% [9/244]; p = 0.484). In ASCVD < 7.5%, HS predicted MACE (aHR:2.34, 95%CI:1.01-5.43; p = 0.048), independent of CAD characteristics. Individuals with HS at ASCVD < 7.5% risk had similar CAD characteristics as patients without HS at < 7.5% ASCVD risk, yet experienced comparable MACE rates as those at ASCVD ≥ 7.5%.

Cost-effectiveness of ultrahigh-resolution photon-counting detector coronary CT angiography for the evaluation of stable chest pain

BackgroundThe increased specificity of ultrahigh-resolution (UHR) photon-counting detector (PCD)-CT over energy-integrating detector (EID)-CT for coronary CT angiography (CCTA) could defer unwarranted downstream tests. The objective of the study was to simulate the cost-effectiveness of UHR CCTA in stable chest pain patients with coronary calcifications. MethodsA decision and simulation model was developed using Monte Carlo simulations with 1000 bootstrap resamples to estimate the costs associated with PCD-CT in lieu of EID-CT for CCTA and the referral for subsequent testing. The model was constructed using the diagnostic accuracy metrics of 55 coronary lesions in patients who underwent CCTA on both CT systems and subsequent invasive coronary angiography (ICA). Sensitivity and specificity were defined for each Coronary Artery Disease Reporting and Data System category. The aggregate healthcare expenditures were derived from the hospital billing system. ResultsAssuming a projected cohort of 15,000 patients over the lifetime of the PCD-CT, its implementation resulted in a 18.9 ​% reduction in the number of functional follow-up tests (6330.3 ​± ​59.5 vs. 5135.7 ​± ​60.6, p ​< ​0.001), a 6.0 ​% reduction in performed ICAs (1447.7 ​± ​36.2 vs. 1360.2 ​± ​34.7, p ​< ​0.001), and a 9.4 ​% decrease in major procedure-related complications. Over a 10-year expected life expectancy, PCD-CT led to an average cost saving of $794.50 ​± ​18.50 per patient and an overall cost difference of $11,917,500 ​± ​4,350,169. ConclusionsPCD-CT has the potential to reduce the financial burden on healthcare systems and procedure-related complications for stable chest pain patients with coronary calcification when compared to EID-CT.

The effectiveness of coronary computed tomography angiography and functional testing for the diagnosis of obstructive coronary artery disease: results from the individual patient data Collaborative Meta-Analysis of Cardiac CT (COME-CCT)

AimTo determine the effectiveness of functional stress testing and computed tomography angiography (CTA) for diagnosis of obstructive coronary artery disease (CAD).Methods and resultsTwo-thousand nine-hundred twenty symptomatic stable chest pain patients were included in the international Collaborative Meta-Analysis of Cardiac CT consortium to compare CTA with exercise electrocardiography (exercise-ECG) and single-photon emission computed tomography (SPECT) for diagnosis of CAD defined as ≥ 50% diameter stenosis by invasive coronary angiography (ICA) as reference standard. Generalised linear mixed models were used for calculating the diagnostic accuracy of each diagnostic test including non-diagnostic results as dependent variables in a logistic regression model with random intercepts and slopes. Covariates were the reference standard ICA, the type of diagnostic method, and their interactions. CTA showed significantly better diagnostic performance (p < 0.0001) with a sensitivity of 94.6% (95% CI 92.7–96) and a specificity of 76.3% (72.2–80) compared to exercise-ECG with 54.9% (47.9–61.7) and 60.9% (53.4–66.3), SPECT with 72.9% (65–79.6) and 44.9% (36.8–53.4), respectively. The positive predictive value of CTA was ≥ 50% in patients with a clinical pretest probability of 10% or more while this was the case for ECG and SPECT at pretest probabilities of ≥ 40 and 28%. CTA reliably excluded obstructive CAD with a post-test probability of below 15% in patients with a pretest probability of up to 74%.ConclusionIn patients with stable chest pain, CTA is more effective than functional testing for the diagnosis as well as for reliable exclusion of obstructive CAD. CTA should become widely adopted in patients with intermediate pretest probability.Systematic review registrationPROSPERO Database for Systematic Reviews—CRD42012002780.Critical relevance statementIn symptomatic stable chest pain patients, coronary CTA is more effective than functional testing for diagnosis and reliable exclusion of obstructive CAD in intermediate pretest probability of CAD.Key PointsCoronary computed tomography angiography showed significantly better diagnostic performance (p < 0.0001) for diagnosis of coronary artery disease compared to exercise-ECG and SPECT.The positive predictive value of coronary computed tomography angiography was ≥ 50% in patients with a clinical pretest probability of at least 10%, for ECG ≥ 40%, and for SPECT 28%.Coronary computed tomography angiography reliably excluded obstructive coronary artery disease with a post-test probability of below 15% in patients with a pretest probability of up to 74%.Graphical

Coronary Artery Calcium Score-Weighted Clinical Likelihood Model Performance in Patients with Stable Chest Pain and Coronary Artery Calcium Scores of Zero.

For individuals with persistent stable chest pain (SCP) and a coronary artery calcium score (CACS) of 0, it might be challenging to establish the best risk assessment method for determining the individuals who will not benefit from further cardiovascular imaging testing (CIT). Thus, we investigated the CACS-weighted clinical likelihood (CACS-CL) model in SCP patients with a CACS of 0. Thus, to assess SCP, we originally enrolled 14,232 individuals for CACS and coronary computed tomography angiography (CCTA) scans between January 2016 and January 2018. Finally, patients with a CACS of 0 were included and followed up ​until January 2022. According to the established CACS-CL cutoffs of 15% and 5%, the associations between coronary artery disease (CAD) and major adverse cardiovascular events (MACEs) in risk groups were evaluated, alongside the net reclassification improvement (NRI). Of the 6689 patients with a CACS of 0, the prevalence of CAD increased significantly (p 0.0001) in patients with higher CACS-CL. However, there was no significant difference in the CAD distribution (p = 0.0637) between patients with CACS-CL 5% and 5-15%. The association between the CACS-CL = 15%-determined risk groups and the occurrence of MACEs was stronger than for a CACS-CL = 5% (adjusted hazard ratio (HR): 7.24 (95% CI: 1.93-16.42) versus 3.68 (95% CI: 1.50-8.26)). Compared with the cutoff for CACS-CL = 5%, the NRI was 10.61% when using a cutoff for CACS-CL = 15%. Among patients with an SCP and CACS of 0, the CACS-CL model provided accurate predictions of CAD and MACEs. Compared to the cutoff for CACS-CL = 5%, the cutoff for CACS-CL = 15% seemed to be more effective and safer for deferring further CIT. NCT04691037.

Abstract 15973: Ambient Air Pollution is Associated With Coronary Artery Disease and Adverse Outcomes in Patients With Stable Chest Pain Across the U.S.: Insights From the PROMISE Trial

Introduction: Air pollution is associated with coronary artery disease (CAD) and cardiovascular (CV) outcomes. Hypothesis: The relationships of air pollutants to CAD and outcomes are independent of traditional CV risk factors and socioeconomic determinants of health (SDoH) and vary by pollutant type. Methods: Clinical and CT data from stable chest pain patients without known CAD in the PROMISE trial, were linked by home zip code to U.S. EPA-derived PM 2.5 and PM 10 (Figure 1a) . CT metrics included any plaque, obstructive CAD (≥50%), and high-risk plaque (HRP); major adverse CV events were defined as death (all cause or CV), myocardial infarction, or unstable angina. Logistic and Cox regressions were adjusted for age, sex, obesity, ASCVD risk, statins, and US Census-based SDoH by zip code. We conducted a mediation analysis for the effect of pollutants on events using obstructive CAD as mediator. Results: In 4,343 individuals (48% men; age: 61±8 years), 46.9% were exposed to PM 2.5 above the standard cut point of 9.5 μg/m 3 and 62.1% to PM 10 ≥15 μg/m 3 . Participants exposed to PM 2.5 ≥9.5 μg/m 3 had 27% higher odds of obstructive CAD (aOR=1.27, 95%CI: 1.03-1.56, p=0.026), not significant for PM 10 . No associations existed between pollutants and any plaque or HRP. PM 2.5 and PM 10 were independently associated with CV events in fully adjusted models (Figure 1b) . In mediation analysis, the effects of PM 2.5 on events were significant (direct effect: OR=1.66, 95%CI: 1.11-2.50, p=0.014; indirect effect: OR=1.06, 95%CI: 1.01-1,12, p=0.022) with comparable results for PM 10 . Conclusions: Air pollution relates independently to adverse events in stable chest pain patients, only partly driven by CAD phenotypes, specifically an association between small particular matter and obstructive CAD. Further studies investigating the pathogenesis of atherosclerotic disease in people exposed to pollution may help form strategies to reduce exposure.

Derivation and validation of a novel functional FFRCT score incorporating the burden of coronary stenosis severity and flow impairment to predict clinical events

BackgroundA score combining the burden of stenosis severity on coronary computed tomography angiography (CCTA) and flow impairment by fractional flow reserve derived from computed tomography (FFRCT) may be a better predictor of clinical events than either parameter alone. MethodsThe Functional FFRCT Score (FFS) combines CCTA and FFRCT parameters in an allocated point-based system. The feasibility of the FFS was assessed in cohort of 72 stable chest pain patients with matched CCTA and FFRCT datasets. Validation was performed using 2 cohorts: (a) 4468 patients from the ADVANCE Registry to define its association with revascularization and major adverse cardiovascular events (MACE); (b) 212 patients from the FORECAST trial to determine predictors of MACE. ResultsThe median calculation time for the FFS was 10 (interquartile range 6–17) seconds, with strong intra-operator and inter-operator agreement (Cohen's Kappa 0.89 (±0.37, p ​< ​0.001) and 0.83 (±0.04, p ​< ​0.001, respectively). The FFS correlated strongly with both the CT-SYNTAX and the Functional CT-SYNTAX scores (rS ​= ​0.808 for both, p ​< ​0.001).In the ADVANCE cohort the FFS had good discriminatory abilities for revascularization with an area under the curve of 0.82, 95 ​% confidence interval (CI) 0.81–0.84, p ​< ​0.001. Patients in the highest FFS tertile had significantly higher rates of revascularization (61 ​% vs 5 ​%, p ​< ​0.001) and MACE (1.9 ​% vs 0.5 ​%, p ​= ​0.001) compared with the lowest FFS tertile.In the FORECAST cohort the FFS was an independent predictor of MACE at 9-month follow-up (hazard ratio 1.04, 95 ​% CI 1.01–1.08, p ​< ​0.01). ConclusionThe FFS is a quick-to-calculate and reproducible score, associated with revascularization and MACE in two distinct populations of stable symptomatic patients.

Combination of computed tomography angiography with coronary artery calcium score for improved diagnosis of coronary artery disease: a collaborative meta-analysis of stable chest pain patients referred for invasive coronary angiography

ObjectivesCoronary computed tomography angiography (CCTA) has higher diagnostic accuracy than coronary artery calcium (CAC) score for detecting obstructive coronary artery disease (CAD) in patients with stable chest pain, while the added diagnostic value of combining CCTA with CAC is unknown. We investigated whether combining coronary CCTA with CAC score can improve the diagnosis of obstructive CAD compared with CCTA alone.MethodsA total of 2315 patients (858 women, 37%) aged 61.1 ± 10.2 from 29 original studies were included to build two CAD prediction models based on either CCTA alone or CCTA combined with the CAC score. CAD was defined as at least 50% coronary diameter stenosis on invasive coronary angiography. Models were built by using generalized linear mixed-effects models with a random intercept set for the original study. The two CAD prediction models were compared by the likelihood ratio test, while their diagnostic performance was compared using the area under the receiver-operating-characteristic curve (AUC). Net benefit (benefit of true positive versus harm of false positive) was assessed by decision curve analysis.ResultsCAD prevalence was 43.5% (1007/2315). Combining CCTA with CAC improved CAD diagnosis compared with CCTA alone (AUC: 87% [95% CI: 86 to 89%] vs. 80% [95% CI: 78 to 82%]; p < 0.001), likelihood ratio test 236.3, df: 1, p < 0.001, showing a higher net benefit across almost all threshold probabilities.ConclusionAdding the CAC score to CCTA findings in patients with stable chest pain improves the diagnostic performance in detecting CAD and the net benefit compared with CCTA alone.Clinical relevance statementCAC scoring CT performed before coronary CTA and included in the diagnostic model can improve obstructive CAD diagnosis, especially when CCTA is non-diagnostic.Key Points• The combination of coronary artery calcium with coronary computed tomography angiography showed significantly higher AUC (87%, 95% confidence interval [CI]: 86 to 89%) for diagnosis of coronary artery disease compared to coronary computed tomography angiography alone (80%, 95% CI: 78 to 82%, p < 0.001).• Diagnostic improvement was mostly seen in patients with non-diagnostic C.• The improvement in diagnostic performance and the net benefit was consistent across age groups, chest pain types, and genders.

Drugless and radiographer led: the start of a new era for CT coronary angiography

ObjectiveSince inception CT coronary angiography (CTCA) has required facilitating beta blockers (BB). However, CT technology has improved rapidly as has radiographer and reporter expertise. Using these factors, we instituted a...

Comparison of risk assessment strategies incorporating coronary artery calcium score with estimation of pretest probability to defer cardiovascular testing in patients with stable chest pain

BackgroundThe risk assessment of patients with stable chest pain (SCP) to defer further cardiovascular testing is crucial, but the most appropriate risk assessment strategy remains unknown. We aimed to compare current strategies to identify low risk SCP patients.Methods5289 symptomatic patients who had undergone coronary artery calcium score (CACS) and coronary computed tomographic angiography scan were identified and followed. Pretest probability (PTP) of obstructive coronary artery disease (CAD) for every patient was estimated according to European Society of Cardiology (ESC)-PTP model and CACS-weighted clinical likelihood (CACS-CL) model, respectively. Based on the 2019 ESC guideline-determined risk assessment strategy (ESC strategy) and CACS-CL model-based risk assessment strategy (CACS-CL strategy), all patients were divided into low and high risk group, respectively. Area under receiver operating characteristic curve (AUC), integrated discrimination improvement (IDI) and net reclassification improvement (NRI) was used.ResultsCACS-CL model provided more robust estimation of PTP than ESC-PTP model did, with a larger AUC (0.838 versus 0.735, p < 0.0001), positive IDI (9%, p < 0.0001) and less discrepancy between observed and predicted probabilities. As a result, compared to ESC strategy which only applied CACS-CL model to patients with borderline ESC-PTP, CACS-CL strategy incorporating CACS with estimation of PTP to entire SCP patients indicated a positive NRI (19%, p < 0.0001) and a stronger association to major adverse cardiovascular events, with hazard ratios: 3.97 (95% confidence intervals: 2.75–5.72) versus 5.11 (95% confidence intervals: 3.40–7.69).ConclusionThe additional use of CACS for all SCP patients in CACS-CL strategy improved the risk assessment of SCP patients to identify individuals at low risk.

The Added Value of a High CT Coronary Artery Calcium Score in the Management of Patients Presenting with Acute Chest Pain vs. Stable Chest Pain.

Contrast computerized tomography (CT) scan is occasionally aborted due to a high coronary artery calcium score (CACS). For the same CACS in our clinical practice, we observed a higher occurrence of severe coronary artery disease (CAD) in patients with acute chest pain (ACP) compared to patients with stable chest pain (SCP). Since it is known that ACP differs in many ways from SCP, the aim of this study was to compare the predictive value of a high CACS for the diagnosis of severe CAD between ACP and SCP patients. This single center observational retrospective study included consecutive patients who underwent cardiac CT for chest pain and were found to have a CACS of &gt;200 Agatston units. Patients were divided into two groups, ACP and SCP. Severe CAD was defined as ≥70% stenosis on coronary CT angiography or invasive coronary angiography. Baseline characteristics and final diagnosis of severe CAD were compared. The cohort included 220 patients, 106 with ACP and 114 with SCP. ACP patients had higher severe CAD rates (60.4% vs. 36.8%; p &lt; 0.001). On multivariate analysis including cardiac risk factors, CACS &gt; 400 au (OR = 2.34 95% CI [1.32-4.15]; p = 0.004) and ACP (OR = 2.54 95% CI [1.45-4.45]; p = 0.001) were independent predictors of severe CAD. The addition of the clinical setting of ACP added significant incremental predictive value for severe stenosis. A high CACS is more associated with severe CAD in patients presenting with ACP than SCP. The findings suggest that the CACS could impact the management of patients during the scan.

Abstract 10369: Meta-Analysis of Coronary Computed Tomography versus Invasive Coronary Angiography in Stable Chest Pain

Background: The coronary computed tomography angiography (CCTA) is a noninvasive alternative tool in diagnosis of coronary artery disease compared to invasive coronary angiography (ICA). However, there is uncertainty regarding its usefulness in reducing major adverse cardiovascular events in stable chest pain patients. Methods: We have searched EMBASE, PubMed, and Cochrane Library (inception through May 24 th , 2022) for randomized controlled trials (RCTs) evaluating CCTA versus ICA in stable chest pain. The Mantel-Haenszel method was used with Paule-Mandel estimator of tau 2 and Hartung-Knapp-Sidik-Jonkman adjustment (given small number of the included studies) to calculate the risk ratio (RR) and 95% confidence interval (CI). Results: Three RCTs with a total of 5,393 patients were included in this study. There was no significant difference between CCTA and ICA in terms of myocardial infarction [RR: 1.12; 95%CI: 0.60; 2.09; I 2 :0%] [Figure ], stroke [RR: 0.52; 95%CI: 0.22; 1.24; I 2 :0%], all-cause mortality [RR: 1.83; 95%CI: 0.17; 20.18; I 2 :50%], or cardiovascular mortality [RR: 0.47; 95%CI: 0.02; 9.15; I 2 :0%]. Conclusion: This meta-analysis suggests that there is no difference between CCTA and ICA for stable chest pain evaluation in terms of myocardial infarction, stroke, all-cause mortality, or cardiovascular mortality.

The association between cardiovascular risk factors and coronary CT angiography findings for predicting obstructive coronary artery disease in Korean patients with stable chest pain

Abstract Background/Introduction The 2019 European Society of Cardiology (ESC) guidelines currently recommend the use of coronary computed tomography angiography (CCTA) as the initial test for diagnosing coronary artery disease (CAD) in symptomatic patients in whom obstructive CAD cannot be excluded by clinical assessment alone. Purpose The purpose of this study is to identify the prevalence of obstructive CAD in patients with stable chest pain, and the correlation between several clinical cardiovascular disease (CVD) risk factors and CCTA findings presented by Coronary Artery Disease Reporting and Data System (CAD-RADS). Methods The present study is a single-center retrospective cross-sectional study. A total of 1,892 patients with stable chest pain who underwent CCTA were enrolled in this study. Diamond-Forrester classification, Framingham risk score (FRS), atherosclerotic CVD (ASCVD) 10-year risk score, coronary artery calcium score (CACS) and CAD-RADS category were obtained from every patient. Results Among 1,892 patients (mean age, 60.5±8.6 years; men, 59.3%), 356 (18.8%) had obstructive CAD according to CCTA. Patients with high and intermediate ASCVD 10-year risk score had 2.59 times (aOR 2.59, 95% CI; 1.58 to 4.23) and 1.66 times (aOR 1.66, 95% CI; 1.04 to 2.65) higher odds of having obstructive CAD than patients with low ASCVD 10-year risk score, respectively (adjusted for Diamond-Forrester classification and CACS group). Higher ASCVD risk scores were significantly associated with higher CAD-RADS category (p&amp;lt;0.001), and patients with CAD-RADS category 3 had ASCVD 10-year risk score of 20.1±12.7. CACS showed the highest discrimination in presence of obstructive CAD, followed by ASCVD 10-year risk score, FRS, and Diamond-Forrester classification (AUC: 0.821 [95% CI; 0.797–0.845]; 0.711 [95% CI; 0.683–0.740]; 0.675 [95% CI; 0.646–0.704]; 0.600 [95% CI; 0.569–0.632], respectively). Conclusion This is the first study of CCTA findings in stable chest pain patients in Korea. The prevalence of obstructive CAD in patients with stable chest pain was 18.8%. Higher ASCVD score is significantly associated with presence of obstructive CAD and higher CAD-RADS category. As coronary stenosis of 50%-69% had a mean ASCVD score of 20.1, we should consider CCTA for identifying obstructive CAD in patients with ASCVD score over 20 with stable chest pain. Funding Acknowledgement Type of funding sources: None.

Economic evaluation of single-photon emission-computed tomography versus stress echocardiography in stable chest pain patients

The timely diagnosis of coronary artery disease (CAD) is an important medical problem. This study aims to assess the cost-effectiveness of Single-Photon Emission-Computed Tomography (SPECT) compared with stress echocardiography in stable chest pain patients. An economic evaluation study was conducted to assess the cost-effectiveness of SPECT versus stress echocardiography in stable chest pain patients without known CAD between April 1, 2017, and September 1, 2018 in Tehran, Iran. This study was performed from a societal perspective. The incremental cost-effectiveness ratio was calculated using a decision tree model. In addition, the robustness of results was examined by deterministic and probabilistic sensitivity analysis. This study showed that the expected cost and expected QALY for Stress echocardiography was $1106.75 and 0.83 respectively. Also, SPECT had expected cost and expected QALY equal to $1622.39 and 0.80 respectively. Finally, Stress echocardiography was the dominant strategy for CAD, with a lower cost and greater effectiveness than SPECT. The stress echocardiography can saved $18,528.17 per QALY. A deterministic and probabilistic sensitivity analysis confirmed the robustness of the results. Stress echocardiography was a more cost-effective method for diagnosing CAD disease in stable chest pain patients without known CAD compared to SPECT.

Addition of FFRct in the diagnostic pathway of patients with stable chest pain to reduce unnecessary invasive coronary angiography(FUSION) : Rationale and design for the multicentre, randomised, controlled FUSION trial.

Coronary computed tomography angiography (CCTA) is widely used in the diagnostic work-up of patients with stable chest pain. CCTA has an excellent negative predictive value, but amoderate positive predictive value for detecting coronary stenosis. Computed tomography-derived fractional flow reserve (FFRct) is anon-invasive, well-validated technique that provides functional assessment of coronary stenosis, improving the positive predictive value of CCTA. However, to determine the value of FFRct in routine clinical practice, apragmatic randomised, controlled trial (RCT) is required. We will conduct an RCT to investigate the impact of adding FFRct analysis in the diagnostic pathway of patients with acoronary stenosis on CCTA on the rate of unnecessary invasive coronary angiography, cost-effectiveness, quality of life and clinical outcome. The FUSION trial is aprospective, multicentre RCT that will randomise 528patients with stable chest pain and anatomical stenosis of ≥ 50% but < 90% in at least one coronary artery of ≥ 2 mm on CCTA, to FFRct-guided care or usual care in a1:1ratio. Follow-up will be 1year. The primary endpoint is the rate of unnecessary invasive coronary angiography within 90days. The FUSION trial will evaluate the use of FFRct in stable chest pain patients from the Dutch perspective. The trial is funded by the Dutch National Health Care Institute as part of the research programme 'Potentially Promising Care' and the results will be used to assess if FFRct reimbursement should be included in the standard health care package.

Are risk factors necessary for pretest probability assessment of coronary artery disease? A patient similarity network analysis of the PROMISE trial

BackgroundPretest probability (PTP) calculators utilize epidemiological-level findings to provide patient-level risk assessment of obstructive coronary artery disease (CAD). However, their limited accuracies question whether dissimilarities in risk factors necessarily result in differences in CAD. Using patient similarity network (PSN) analyses, we wished to assess the accuracy of risk factors and imaging markers to identify ≥50% luminal narrowing on coronary CT angiography (CCTA) in stable chest-pain patients. MethodsWe created four PSNs representing: patient characteristics, risk factors, non-coronary imaging markers and calcium score. We used spectral clustering to group individuals with similar risk profiles. We compared PSNs to a contemporary PTP score incorporating calcium score and risk factors to identify ≥50% luminal narrowing on CCTA in the CT-arm of the PROMISE trial. We also conducted subanalyses in different age and sex groups. ResultsIn 3556 individuals, the calcium score PSN significantly outperformed patient characteristic, risk factor, and non-coronary imaging marker PSNs (AUC: 0.81 vs. 0.57, 0.55, 0.54; respectively, p ​< ​0.001 for all). The calcium score PSN significantly outperformed the contemporary PTP score (AUC: 0.81 vs. 0.78, p ​< ​0.001), and using 0, 1–100 and ​> ​100 cut-offs provided comparable results (AUC: 0.81 vs. 0.81, p ​= ​0.06). Similar results were found in all subanalyses. ConclusionCalcium score on its own provides better individualized obstructive CAD prediction than contemporary PTP scores incorporating calcium score and risk factors. Risk factors may not be able to improve the diagnostic accuracy of calcium score to predict ≥50% luminal narrowing on CCTA.

Diagnostic and Clinical Value of FFRCT in Stable Chest Pain Patients With Extensive Coronary Calcification: The FACC Study

BackgroundThe influence of extensive coronary calcifications on the diagnostic and prognostic value of coronary computed tomography angiography–derived fractional flow reserve (FFRCT) has been scantily investigated. ObjectivesThe purpose of this study was to investigate the diagnostic and short-term role of FFRCT in chest pain patients with Agatston score (AS) >399. MethodsThis was a prospective multicenter study of 260 stable patients with suspected coronary artery disease (CAD) and AS >399. FFRCT was measured blinded by an independent core laboratory. All patients underwent invasive coronary angiography (ICA) and FFR if indicated. The agreement of FFRCT ≤0.80 with hemodynamically significant CAD on ICA/FFR (≥50% left main or ≥70% epicardial artery stenosis and/or FFR ≤0.80) was assessed. Patients undergoing FFR had colocation FFRCT measured, and the lowest per-patient FFRCT was registered in all patients. The association among per-patient FFRCT, coronary revascularization, and major clinical events (all-cause mortality, myocardial infarction, or unstable angina hospitalization) at 90-day follow-up was evaluated. ResultsMedian age and AS were 68.5 years (IQR: 63-74 years) and 895 (IQR: 587-1,513), respectively. FFRCT was ≤0.80 in 204 patients (78%). Colocation FFRCT (n = 112) showed diagnostic accuracy, sensitivity, and specificity to identify hemodynamically significant CAD of 71%, 87%, and 54%. The area under the receiver-operating characteristics curve (AUC) was 0.75. When using the lowest FFRCT (n = 260), per-patient accuracy, sensitivity, and specificity were 57%, 95%, and 32%, respectively. The AUC was 0.84. A total of 85 patients underwent revascularization, and FFRCT was ≤0.80 in 96% of these. During follow-up, major clinical events occurred in 3 patients (1.2%), all with FFRCT ≤0.80. ConclusionsMost patients with AS >399 had FFRCT ≤0.80. Using ICA/FFR as the reference revealed a moderate diagnostic accuracy of colocation FFRCT. Compared with the lowest per-patient FFRCT, colocation FFRCT measurement improved diagnostic accuracy and specificity. The 90-day follow-up was favorable with few coronary revascularizations and no major clinical events occurring in patients with FFRCT >0.80. (Use of FFR-CT in Stable Intermediate Chest Pain Patients With Severe Coronary Calcium Score [FACC]; NCT03548753)

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

Estimating the real-world performance of the PROMISE minimal-risk tool

Stable chest pain is a common indication for cardiac catheterization. We assessed the prognostic value of the Prospective Multicenter Imaging Study for Evaluation (PROMISE) Minimal-Risk Tool in identifying patients who are at very low risk of obstructive coronary artery disease (CAD) or downstream cardiovascular adverse outcomes. We applied the PROMISE Minimal-Risk Tool to consecutive patients without known CAD who underwent elective cardiac catheterization for stable angina from January 1, 2000 to December 31, 2014 in the Duke Databank for Cardiovascular Disease (DDCD). Patients with scores >0.46 (top decile of lowest-risk from the PROMISE cohort) were classified as low-risk. Logistic regression modeling compared likelihood of freedom from obstructive coronary artery disease on index angiography, 2-year survival, and 2-year survival free of myocardial infarction (MI) and MI/revascularization between low- and non low-risk patients. Alternative cut points to define low- risk patients were also explored. Among 6251 patients undergoing cardiac catheterization for stable chest pain, 1082 (17.3%) were low-risk per the PROMISE minimal-risk tool. Among low risk patients, obstructive coronary artery disease was observed in 14.9% and left main disease (≥ 50% Stenosis) was rare (0.9%). Compared with other patients, low risk patients had a higher likelihood of freedom from obstructive coronary disease on index catheterization (85.1% vs. 44.2%, OR 4.84, 95% CI 4.06-5.77). Low risk patients had significantly higher survival (98.2% vs. 94.4%, OR 3.18, 95% CI 1.99-5.08), MI-free survival (97.2% vs. 91.9%, OR 3.03, 95% CI 2.07-4.45), and MI/revascularization-free survival (86.2 vs. 59.9%, OR 4.19, 95% CI 3.48-5.05) at 2 years than non-low risk patients. Operating characteristics for predicting the outcomes of interest varied modestly depending on the low-risk cut-point used but the positive predictive value for 2 year freedom from death was >98% regardless. The PROMISE minimal-risk tool identifies 17% of stable chest pain patients referred to cardiac catheterization as low risk. These patients have a low prevalence of obstructive CAD and better survival than non-low risk patients. While this suggests that these patients are unlikely to benefit from catheterization, further research is needed to confirm a favorable downstream prognosis with medical management alone.

Risk Stratification With the Use of Coronary Computed Tomographic Angiography in Patients With Nonobstructive Coronary Artery Disease

ObjectivesThe purpose of this study was to develop a risk prediction model for patients with nonobstructive CAD. BackgroundAmong stable chest pain patients, most cardiovascular (CV) events occur in those with nonobstructive coronary artery disease (CAD). Thus, developing tailored risk prediction approaches in this group of patients, including CV risk factors and CAD characteristics, is needed. MethodsIn PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) computed tomographic angiography patients, a core laboratory assessed prevalence of CAD (nonobstructive 1% to 49% left main or 1% to 69% stenosis any coronary artery), degree of stenosis (minimal: 1% to 29%; mild: 30% to 49%; or moderate: 50% to 69%), high-risk plaque (HRP) features (positive remodeling, low-attenuation plaque, and napkin-ring sign), segment involvement score (SIS), and coronary artery calcium (CAC). The primary end point was an adjudicated composite of unstable angina pectoris, nonfatal myocardial infarction, and death. Cox regression analysis determined independent predictors in nonobstructive CAD. ResultsOf 2,890 patients (age 61.7 years, 46% women) with any CAD, 90.4% (n = 2,614) had nonobstructive CAD (mean age 61.6 yrs, 46% women, atherosclerotic cardiovascular disease [ASCVD] risk 16.2%). Composite events were independently predicted by ASCVD risk (hazard ratio [HR]: 1.03; p = 0.001), degree of stenosis (30% to 69%; HR: 1.91; p = 0.011), and presence of ≥2 HRP features (HR: 2.40; p = 0.008). Addition of ≥2 HRP features to: 1) ASCVD and CAC; 2) ASCVD and SIS; or 3) ASCVD and degree of stenosis resulted in a statistically significant improvement in model fit (p = 0.0036; p = 0.0176; and p = 0.0318; respectively). Patients with ASCVD ≥7.5%, any HRP, and mild/moderate stenosis had significantly higher event rates than those who did not meet those criteria (3.0% vs. 6.2%; p = 0.007). ConclusionsAdvanced coronary plaque features have incremental value over total plaque burden for the discrimination of clinical events in low-risk stable chest pain patients with nonobstructive CAD. This may be a first step to improve prevention in this cohort with the highest absolute risk for CV events.

Rationale, design, and baseline characteristics of Chinese registry in early detection and risk stratification of coronary plaques (C-STRAT) study.

Rationale, design, and baseline characteristics of Chinese registry in early detection and risk stratification of coronary plaques (C-STRAT) study.