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Koopman MY, Willemsen RTA, van der Harst P, van Bruggen R, Gratama JWC, Braam R, van Ooijen PMA, Doggen CJM, Dinant GJ, Kietselaer B, Vliegenthart R. The Diagnostic and Prognostic Value of Coronary Calcium Scoring in Stable Chest Pain Patients: A Narrative Review. ROFO-FORTSCHR RONTG 2022; 194:257-265. [PMID: 35081649 PMCID: PMC8837467 DOI: 10.1055/a-1662-5711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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:
Citation Format
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Affiliation(s)
| | | | - Pim van der Harst
- Cardiology, University Medical Centre Utrecht Department of Cardiology, Utrecht, Netherlands.,Division Heart and Lungs, University Medical Centre Groningen, Netherlands
| | - Rykel van Bruggen
- Primary Health Care, Multicenter General Practitioners Organisation "HuisartsenOrganisatie Oost-Gelderland", Apeldoorn, Netherlands
| | | | | | - Peter M A van Ooijen
- Data Science Center in Health, University Medical Centre Groningen, Netherlands.,Radiation Oncology, University Medical Centre Groningen, Netherlands
| | - Carine J M Doggen
- Health Technology & Services Research, Techmed Centre, University of Twente, Enschede, Netherlands
| | | | - Bas Kietselaer
- Cardiology, Zuyderland Medical Centre Sittard-Geleen, Netherlands
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Bettencourt N, Mendes L, Fontes JP, Matos P, Ferreira C, Botelho A, Carvalho S, Durazzo A, Faustino A, Ladeiras-Lopes R, Vasconcelos M, Vieira C, Correia M, Ferreira AM, Ferreira N, Pires‐Morais G, Almeida AG, Ferreira MJV, Teixeira M. Consensus document on chronic coronary syndrome assessment and risk stratification in Portugal: A position paper statement from the [Portuguese Society of Cardiology’s] Working Groups on Nuclear Cardiology, Magnetic Resonance and Cardiac Computed Tomography, Echocardiography, and Exercise Physiology and Cardiac Rehabilitation. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.repce.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Bettencourt N, Mendes L, Fontes JP, Matos P, Ferreira C, Botelho A, Carvalho S, Durazzo A, Faustino A, Ladeiras Lopes R, Vasconcelos M, Vieira C, Correia M, Ferreira AM, Ferreira N, Pires-Morais G, G Almeida A, Ferreira MJV, Teixeira M. Consensus document on chronic coronary syndrome assessment and risk stratification in Portugal: A position paper statement from the [Portuguese Society of Cardiology's] Working Groups on Nuclear Cardiology, Magnetic Resonance and Cardiac Computed Tomography, Echocardiography, and Exercise Physiology and Cardiac Rehabilitation. Rev Port Cardiol 2020; 41:241-251. [PMID: 33342714 DOI: 10.1016/j.repc.2020.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/24/2020] [Accepted: 10/29/2020] [Indexed: 01/19/2023] Open
Abstract
Despite constant medical evolution, the reimbursement policy of Portuguese National Health Service (NHS) for the study and risk stratification of coronary heart disease has remained unchanged for several decades. Lack of adjustment to contemporary clinical practice has long been evident. However, the recent publication of the European Guidelines for diagnosis and treatment of chronic coronary syndromes further highlighted this gap and the urgent need for a change. Prompted by these Guidelines, the Working Group on Nuclear Cardiology, Cardiac Magnetic Resonance and Cardiac CT, the Working Group on Echocardiography and the Working Group on Stress Pathophysiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology, began a process of joint reflection on the current limitations and how these recommendations could be applied in Portugal. To this end, the authors suggest that the new imaging methods (stress echocardiogram, cardiac computed tomography and cardiac magnetic resonance), should be added to exercise treadmill stress test and myocardial perfusion scintigraphy in the available exam portfolio within the Portuguese NHS. This change would allow full adoption of European guidelines and a better use of tests, according to clinical context, availability and local specificities. The adoption of clinical guidance standards, based on these assumptions, would translate into a qualitative improvement in the management of these patients and would promote an effective use of the available resources, with potential health and financial gains.
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Affiliation(s)
| | | | - José Paulo Fontes
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | | | - Catarina Ferreira
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Faculdade de Ciências da Saúde, Universidade da Beira Interior, Vila Real, Portugal
| | - Ana Botelho
- Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Sofia Carvalho
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Anaí Durazzo
- Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Ana Faustino
- Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Ricardo Ladeiras Lopes
- Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; Faculdade de Medicina do Porto, Porto, Portugal
| | - Mariana Vasconcelos
- Faculdade de Medicina do Porto, Porto, Portugal; Centro Hospitalar Universitário São João, Porto, Portugal
| | | | - Miguel Correia
- Centro Hospitalar Tondela/Viseu e Hospital CUF-Viseu, Viseu, Portugal
| | - António M Ferreira
- Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal; Hospital da Luz, Lisboa, Portugal
| | - Nuno Ferreira
- Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | | | - Ana G Almeida
- Centro Hospitalar Lisboa Norte, Hospital de Santa Maria e Faculdade de Medicina de Lisboa, Lisboa, Portugal
| | - Maria João Vidigal Ferreira
- Centro Hospitalar Universitário de Coimbra e Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
| | - Madalena Teixeira
- Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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Faggiano P, Dasseni N, Gaibazzi N, Rossi A, Henein M, Pressman G. Cardiac calcification as a marker of subclinical atherosclerosis and predictor of cardiovascular events: A review of the evidence. Eur J Prev Cardiol 2019; 26:1191-1204. [DOI: 10.1177/2047487319830485] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Pompilio Faggiano
- Cardiology Division, Spedali Civili Hospital and University of Brescia, Italy
| | - Nicolò Dasseni
- Cardiology Division, Spedali Civili Hospital and University of Brescia, Italy
| | | | - Andrea Rossi
- Cardiology Division, University of Verona, Italy
| | - Michael Henein
- Department of Public Health and Clinical Medicine, Umea University, Sweden
- St George University, London, UK
- Brunel University, London, UK
| | - Gregg Pressman
- Heart and Vascular Institute, Einstein Medical Center, Philadelphia, USA
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Knol RJJ, Kan H, Wondergem M, Cornel JH, Umans VAWM, van der Ploeg T, van der Zant FM. Exercise Electrocardiogram Neither Predicts Nor Excludes Coronary Artery Disease in Women with Low to Intermediate Risk. J Womens Health (Larchmt) 2018; 27:476-484. [PMID: 29297745 DOI: 10.1089/jwh.2017.6433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIM The value of exercise electrocardiogram (ExECG) in symptomatic female patients with low to intermediate risk for significant coronary artery disease (CAD) has been under debate for many years, and nondiagnostic or even erroneous test results are frequently encountered. Cardiac-CT may be more appropriate to exclude CAD in women. This study compares the results of ExECGs with those of cardiac-CTs, performed within a time frame of 1 month in an all-comers female chest pain population. PATIENTS AND METHODS Five hundred fifty-one consecutive female patients from a patient registry were included. ExECGs were negative in 324 (59%), positive in 14 (3%), and nondiagnostic in 213 (39%) patients. CAD was revealed by cardiac-CT in 57% of the women with negative ExECG. No signs of CAD were present on cardiac-CT in 64% of the women with a positive ExECG. Cardiac-CT showed presence of CAD in 268/551 (49%) patients, of whom 56/268 (21%) was diagnosed with ≥50% stenosis. The ExECG of the latter group was negative in 26 (46%), inconclusive in 29 (52%), and positive in 1 (2%). Considering ≥50% stenosis at cardiac-CT as the reference, sensitivity, specificity, PPV, and NPV of ExECG for the present population were 3.7%, 95.7%, 7.1%, and 91.7%, respectively. Similar diagnostic performance was calculated when considering ≥70% stenosis at cardiac-CT as the reference. CONCLUSION ExECG failed to detect CAD in more than half of this cohort and in almost half of women with >50% stenosis at cardiac-CT. Importantly, no CAD was detected by cardiac-CT in 64% of women with a positive ExECG. ExECG is therefore questionable as a diagnostic strategy in women with low-to-intermediate risk of CAD, although prospective studies are warranted to determine whether replacing ExECG by cardiac-CT provides better prognoses.
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Affiliation(s)
- Remco J J Knol
- 1 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .,2 Department of Nuclear Medicine, Northwest Clinics , Alkmaar, The Netherlands
| | - Huub Kan
- 1 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .,2 Department of Nuclear Medicine, Northwest Clinics , Alkmaar, The Netherlands
| | - Maurits Wondergem
- 1 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .,2 Department of Nuclear Medicine, Northwest Clinics , Alkmaar, The Netherlands
| | - Jan H Cornel
- 1 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .,3 Department of Cardiology, Northwest Clinics , Alkmaar, The Netherlands
| | - Victor A W M Umans
- 1 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .,3 Department of Cardiology, Northwest Clinics , Alkmaar, The Netherlands
| | - Tjeerd van der Ploeg
- 4 Department of Statistics and Clinical Epidemiology, Northwest Clinics , Alkmaar, The Netherlands
| | - Friso M van der Zant
- 1 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .,2 Department of Nuclear Medicine, Northwest Clinics , Alkmaar, The Netherlands
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