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.
Does Coronary Artery Calcium Scoring Add to the Predictive Value of Coronary Computed Tomography Angiography for Adverse Cardiovascular Events in Low-risk Chest Pain Patients?