Ajay Yerramasu1, Avijit Lahiri2, Shreenidhi Venuraju1, Alain Dumo1, David Lipkin1, S Richard Underwood3, Roby D Rakhit4, Deven J Patel5. 1. Clinical Imaging and Research Centre, Wellington Hospital, London, UK. 2. Clinical Imaging and Research Centre, Wellington Hospital, London, UK University of Middlesex, London, UK. 3. National Heart and Lung Institute, Imperial College London, London, UK Royal Brompton Hospital, Sydney St, London SW3 6NP, UK srunderwood@imperial.ac.uk. 4. Royal Free London Foundation Trust, London, UK. 5. Barnet and Chase Farm Hospitals NHS Trust, London, UK.
Abstract
BACKGROUND: Coronary artery calcium (CAC) imaging by unenhanced computed X-ray tomography (CT) is recommended as an initial diagnostic test for patients with stable chest pain symptoms but a low likelihood (10-29%) of underlying obstructive coronary artery disease (CAD) after clinical assessment. The recommendation has not previously been tested prospectively in a rapid access chest pain clinic (RACPC). METHODS: We recruited 300 consecutive patients presenting with stable chest pain to the RACPC of three hospitals. All patients underwent CAC imaging, followed by invasive coronary angiography (ICA) in patients with CAC ≥ 1000 Agatston units (Au) and CT coronary angiography (CTCA) in those with CAC <1000. Patients with 50-70% stenosis on CTCA underwent myocardial perfusion scintigraphy (MPS) while those with ≥ 70% stenosis underwent ICA. Obstructive CAD was defined as ≥ 70% stenosis on ICA or the presence of inducible ischaemia on MPS. Patients were followed up clinically for a mean of 17 (SD 6) months. RESULTS: The mean patient age was 60.6 (SD 9.6) years and 48% were males. Obstructive CAD was found in 56 (19%) patients, of whom 42 (14%) underwent revascularization. CAC was zero in 131 (44%) patients, of whom two (1.5%) had obstructive CAD and one (0.8%) underwent revascularization. The sensitivity, specificity, negative predictive value, and positive predictive value of CAC ≥ 1 for detection of obstructive CAD were 96, 53, 32, and 98%, respectively. None of the 57 patients with low pre-test probability of CAD and zero CAC had obstructive CAD or suffered a cardiovascular event during the follow-up. CONCLUSION: Patients with stable chest pain symptoms but a low likelihood of CAD can safely be diagnosed as not having obstructive CAD in the absence of detectable coronary calcification by unenhanced CT. Patients with CAC >400 Au have a high prevalence of obstructive CAD and further investigation with ICA or functional imaging may be warranted rather than CTCA. These findings support NICE guidance for the investigation of stable chest pain. ClinicalTrials gov identifier: NCT01464203. Published on behalf of the European Society of Cardiology. All rights reserved.
BACKGROUND: Coronary artery calcium (CAC) imaging by unenhanced computed X-ray tomography (CT) is recommended as an initial diagnostic test for patients with stable chest pain symptoms but a low likelihood (10-29%) of underlying obstructive coronary artery disease (CAD) after clinical assessment. The recommendation has not previously been tested prospectively in a rapid access chest pain clinic (RACPC). METHODS: We recruited 300 consecutive patients presenting with stable chest pain to the RACPC of three hospitals. All patients underwent CAC imaging, followed by invasive coronary angiography (ICA) in patients with CAC ≥ 1000 Agatston units (Au) and CT coronary angiography (CTCA) in those with CAC <1000. Patients with 50-70% stenosis on CTCA underwent myocardial perfusion scintigraphy (MPS) while those with ≥ 70% stenosis underwent ICA. Obstructive CAD was defined as ≥ 70% stenosis on ICA or the presence of inducible ischaemia on MPS. Patients were followed up clinically for a mean of 17 (SD 6) months. RESULTS: The mean patient age was 60.6 (SD 9.6) years and 48% were males. Obstructive CAD was found in 56 (19%) patients, of whom 42 (14%) underwent revascularization. CAC was zero in 131 (44%) patients, of whom two (1.5%) had obstructive CAD and one (0.8%) underwent revascularization. The sensitivity, specificity, negative predictive value, and positive predictive value of CAC ≥ 1 for detection of obstructive CAD were 96, 53, 32, and 98%, respectively. None of the 57 patients with low pre-test probability of CAD and zero CAC had obstructive CAD or suffered a cardiovascular event during the follow-up. CONCLUSION:Patients with stable chest pain symptoms but a low likelihood of CAD can safely be diagnosed as not having obstructive CAD in the absence of detectable coronary calcification by unenhanced CT. Patients with CAC >400 Au have a high prevalence of obstructive CAD and further investigation with ICA or functional imaging may be warranted rather than CTCA. These findings support NICE guidance for the investigation of stable chest pain. ClinicalTrials gov identifier: NCT01464203. Published on behalf of the European Society of Cardiology. All rights reserved.
Authors: Moniek Y Koopman; Robert T A Willemsen; Pim van der Harst; Rykel van Bruggen; Jan Willem C Gratama; Richard Braam; Peter M A van Ooijen; Carine J M Doggen; Geert-Jan Dinant; Bas Kietselaer; Rozemarijn Vliegenthart Journal: Rofo Date: 2022-01-26
Authors: Moniek Y Koopman; Jorn J W Reijnders; Robert T A Willemsen; Rykel van Bruggen; Carine J M Doggen; Bas Kietselaer; Martijn J Oude Wolcherink; Peter M A van Ooijen; Jan Willem C Gratama; Richard Braam; Matthijs Oudkerk; Pim van der Harst; Geert-Jan Dinant; Rozemarijn Vliegenthart Journal: BMJ Open Date: 2022-04-19 Impact factor: 3.006
Authors: Cvetan Trpkov; Alexei Savtchenko; Zhiying Liang; Patrick Feng; Danielle A Southern; Stephen B Wilton; Matthew T James; Erin Feil; Ilias Mylonas; Robert J H Miller Journal: Int J Cardiol Heart Vasc Date: 2021-06-19
Authors: Alireza Almasi; Hamidreza Pouraliakbar; Ahmad Sedghian; Mohammad Ali Karimi; Ata Firouzi; Mahmood Tehrai Journal: Pol J Radiol Date: 2014-06-30