Differences in the association of total versus local coronary artery calcium with acute coronary syndrome and culprit lesions in patients with acute chest pain: The coronary calcium paradox

Introduction: Coronary computed tomography angiography (CCTA) is a class IIA recommendation in low-intermediate risk patients with suspected acute coronary syndrome (ACS) and a normal or nondiagnostic cardiac biomarker and ECG. However, there is little consensus on whether absence of coronary artery calcium (CAC) can safely identify patients with stable and acute chest pain (CP) who can avoid more advanced downstream testing. In this study, we conducted a systematic analysis investigating utility of CAC zero in ruling out obstructive coronary artery disease (CAD) among patients with stable and acute CP undergoing coronary CT angiography (CCTA). Methods: We searched online databases (PubMed, MEDLINE) for original research articles published between 2005 and 2020 examining the relationship between CAC and significant stenosis on CCTA (defined as >50% coronary luminal narrowing) among patients with stable and acute chest pain. Results: A systematic review of published articles revealed 18 studies including 27,719 patients with stable CP and 12 studies including 7,184 patients with acute CP undergoing simultaneous CCTA and CAC scoring. Overall, 12,664 (45%, 95% CI: 39%-50%) patients with stable CP and 4,327 (56%, 95% CI: 48%-64%) patients with acute CP had CAC zero. The pooled prevalence of obstructive CAD among those with CAC=0 was 3% (95% CI: 2%-4%) among stable CP patients and 2% (95% CI: 1%-3%) among acute CP patients. The negative predictive values for any CAC ruling out obstructive disease were 97% (95% CI: 96-98%) and 98% (95% CI: 96-100%), respectively (Figure). Conclusions: Among over 34,000 patients with stable and acute CP patients undergoing CCTA, the absence of CAC was associated with a very low likelihood of obstructive CAD. These findings support role of CAC zero in a value-based healthcare delivery model as a gatekeeper for more advanced testing.

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Predictors of myocardial damage prior to hospital admission among patients with acute chest pain or other symptoms raising a suspicion of acute coronary syndrome

Coronary Artery Disease ◽

10.1097/01.mca.0000063503.13456.0d ◽

2003 ◽

Vol 14 (3) ◽

pp. 225-231 ◽

Cited By ~ 12

Author(s):

Leif Svensson ◽

Leif Isson ◽

Christer Axelsson ◽

Rolf Nordlander ◽

Johan Herlitz

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Hospital Admission ◽

Acute Chest Pain ◽

Myocardial Damage ◽

Coronary Syndrome

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101 Incorporation of stress echocardiography into an acute chest pain service provides excellent feasibility, early triaging and accurate risk stratification of patients with suspected acute coronary syndrome but non-diagnostic ECG and normal 12-h troponin

Heart ◽

10.1136/heartjnl-2012-301877b.101 ◽

2012 ◽

Vol 98 (Suppl 1) ◽

pp. A58.2-A59

Author(s):

B N Shah ◽

G Balaji ◽

A Al Hajiri ◽

I S Ramzy ◽

S Ahmadvazir ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Risk Stratification ◽

Stress Echocardiography ◽

Acute Chest Pain ◽

Coronary Syndrome

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Novel Emergency Department Risk Score Discriminates Acute Coronary Syndrome Among Chest Pain Patients With Known Coronary Artery Disease

Critical Pathways in Cardiology ◽

10.1097/hpc.0000000000000091 ◽

2016 ◽

Vol 15 (4) ◽

pp. 138-144 ◽

Cited By ~ 1

Author(s):

Matthew T. Crim ◽

Scott A. Berkowitz ◽

Mustapha Saheed ◽

Jason Miller ◽

Amy Deutschendorf ◽

...

Keyword(s):

Coronary Artery Disease ◽

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Coronary Artery ◽

Risk Score ◽

Coronary Syndrome ◽

Artery Disease ◽

Pain Patients

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Chest pain and chest pain units

10.1093/med/9780199687039.003.0008_update_001 ◽

2018 ◽

Author(s):

Eric Durand ◽

Aurès Chaib ◽

Etienne Puymirat ◽

Nicolas Danchin

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Acute Coronary Syndromes ◽

Acute Chest Pain ◽

The United States ◽

Cardiac Biomarkers ◽

Coronary Syndrome ◽

Cardiology Department ◽

Coronary Syndromes ◽

Rule Out

Patients presenting at the emergency department with acute chest pain and suspected to represent an acute coronary syndrome were classically admitted as routine to the cardiology department, resulting in expensive and time-consuming evaluations. However, 2-5% of patients with acute coronary syndromes were discharged home inappropriately, resulting in increased mortality. To address the inability to exclude the diagnosis of acute coronary syndrome, chest pain units were developed, particularly in the United States. These provide an environment where serial electrocardiograms, cardiac biomarkers, and provocative testing can be performed to confirm or rule out an acute coronary syndrome. Eligible candidates include the majority of patients with non-diagnostic electrocardiograms. The results have been impressive; chest pain units have markedly reduced adverse events, while simultaneously increasing the rate of safe discharge by 36%. Despite evidence to suggest that care in chest pain units is more effective for such patients, the percentage of emergency or cardiology departments setting up chest pain units remains low in Europe.

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