Ali M Alshahrani1,2, Hamza Mahmood1, George A Wells3, Alomgir Hossain3, Frank J Rybicki4, Stephan Achenbach5, Mouaz H Al-Mallah6, Daniele Andreini7, Jeroen J Bax8, Daniel S Berman9, Matthew J Budoff10, Filippo Cademartiri11, Tracy Q Callister12, Hyuk-Jae Chang13, Kavitha Chinnaiyan14, Ricardo C Cury15, Augustin DeLago16, Gudrun Feuchtner17, Martin Hadamitzky18, Joerg Hausleiter19, Philipp A Kaufmann20, Yong-Jin Kim21, Jonathon A Leipsic22, Erica Maffei23, Hugo Marques24, Gianluca Pontone7, Gilbert Raff14, Ronen Rubinshtein25, Leslee J Shaw26, Todd C Villines27,28, Fay Y Lin29, James K Min29, Benjamin J Chow1,4. 1. Department of Medicine-Cardiology (A.M.A., H. Mahmood, B.J.C.), University of Ottawa Heart Institute, Canada. 2. Department of Cardiac Sciences, King Fahad Cardiac Center, King Saud University Riyadh, Saudi Arabia (A.M.A.). 3. Cardiovascular Research Method Center (G.A.W., A.H.), University of Ottawa Heart Institute, Canada. 4. Department of Radiology, University of Ottawa Faculty of Medicine, Ottawa Hospital Research Institute, Canada (F.J.R., B.J.C.). 5. Department of Medicine, University of Erlangen, Germany (S.A.). 6. Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX (M.H.A.-M.). 7. Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, Milan, Italy (D.A., G.P.). 8. Department of Cardiology, Leiden University Medical Center, the Netherlands (J.J.B.). 9. Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA (D.S.B.). 10. Department of Medicine, Los Angeles Biomedical Research Institute, Torrance, CA (M.J.B.). 11. Department of Radiology, Cardiovascular Imaging Center, Naples, Italy (F.C.). 12. Tennessee Heart and Vascular Institute, Hendersonville (T.Q.C.). 13. Division of Cardiology, Severance Cardiovascular Hospital and Severance Biomedical Science Institute, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea (H.-J.C.). 14. William Beaumont Hospital, Royal Oaks, MI (K.C., G.R.). 15. Baptist Cardiac and Vascular Institute, Miami, FL (R.C.C.). 16. Capitol Cardiology Associates, Albany, NY (A.D.). 17. Department of Radiology, Medical University of Innsbruck, Austria (G.F.). 18. Department of Radiology and Nuclear Medicine, German Heart Center Munich, Germany (M.H.). 19. Medizinische Klinik I der Ludwig-Maximilians-UniversitätMünchen, Munich, Germany (J.H.). 20. University Hospital, Zurich, Switzerland (P.A.K.). 21. Seoul National University Hospital, South Korea (Y.-J.K.). 22. Department of Medicine and Radiology, University of British Columbia, Vancouver, Canada (J.A.L.). 23. Department of Radiology, Area Vasta 1/ASUR Marche, Urbino, Italy (E.M.). 24. Unit of Cardiovascular Imaging, Hospital da Luz, Lisboa, Portugal (H. Marques). 25. Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel (R.R.). 26. Department of Radiology (L.J.S.), New York-Presbyterian Hospital and the Weill Cornell Medical College. 27. Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.). 28. Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD (T.C.V.). 29. Department of Radiology (F.Y.L., J.K.M.), New York-Presbyterian Hospital and the Weill Cornell Medical College.
Abstract
BACKGROUND: Coronary artery calcification is a marker of underlying atherosclerotic vascular disease. The absence of coronary artery calcification is associated with a low prevalence of obstructive coronary artery disease (CAD), but it cannot be ruled out completely. We sought to develop a clinical tool that can be added to Agatston score of zero to rule out obstructive CAD with high accuracy. METHODS: We developed a clinical score retrospectively from a cohort of 4903 consecutive patients with an Agatston score of zero. Patients with prior diagnosis of CAD, coronary percutaneous coronary intervention, or surgical revascularization were excluded. Obstructive CAD was defined as any epicardial vessel diameter narrowing of ≥50%. The score was validated using an external cohort of 4290 patients with an Agatston score of zero from a multinational registry. RESULTS: The score consisted of 7 variables: age, sex, typical chest pain, dyslipidemia, hypertension, family history, and diabetes mellitus. The model was robust with an area under the curve of 0.70 (95% CI, 0.65-0.76) in the derivation cohort and 0.69 (95% CI, 0.65-0.72) in the validation cohort. Patients were divided into 3 risk groups based on the score: low (≤6), intermediate (7-13), and high (≥14). Patients who score ≤6 have a negative likelihood ratio of 0.42 for obstructive CAD, whereas those who score ≥14 have a positive likelihood ratio of >5.5 for obstructive CAD. The outcome was ruled out in >98% of patients with a score ≤6 in the validation cohort. CONCLUSIONS: We developed a score that may be used to identify the likelihood of obstructive CAD in patients with an Agatston score of zero, which may be used to direct the need for additional testing. However, the results of this retrospective analysis are hypothesis generating and before clinical implementation should be validated in a trial with a prospectively collected data.
BACKGROUND:Coronary artery calcification is a marker of underlying atherosclerotic vascular disease. The absence of coronary artery calcification is associated with a low prevalence of obstructive coronary artery disease (CAD), but it cannot be ruled out completely. We sought to develop a clinical tool that can be added to Agatston score of zero to rule out obstructive CAD with high accuracy. METHODS: We developed a clinical score retrospectively from a cohort of 4903 consecutive patients with an Agatston score of zero. Patients with prior diagnosis of CAD, coronary percutaneous coronary intervention, or surgical revascularization were excluded. Obstructive CAD was defined as any epicardial vessel diameter narrowing of ≥50%. The score was validated using an external cohort of 4290 patients with an Agatston score of zero from a multinational registry. RESULTS: The score consisted of 7 variables: age, sex, typical chest pain, dyslipidemia, hypertension, family history, and diabetes mellitus. The model was robust with an area under the curve of 0.70 (95% CI, 0.65-0.76) in the derivation cohort and 0.69 (95% CI, 0.65-0.72) in the validation cohort. Patients were divided into 3 risk groups based on the score: low (≤6), intermediate (7-13), and high (≥14). Patients who score ≤6 have a negative likelihood ratio of 0.42 for obstructive CAD, whereas those who score ≥14 have a positive likelihood ratio of >5.5 for obstructive CAD. The outcome was ruled out in >98% of patients with a score ≤6 in the validation cohort. CONCLUSIONS: We developed a score that may be used to identify the likelihood of obstructive CAD in patients with an Agatston score of zero, which may be used to direct the need for additional testing. However, the results of this retrospective analysis are hypothesis generating and before clinical implementation should be validated in a trial with a prospectively collected data.
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Authors: James K Min; Allison Dunning; Fay Y Lin; Stephan Achenbach; Mouaz H Al-Mallah; Daniel S Berman; Matthew J Budoff; Filippo Cademartiri; Tracy Q Callister; Hyuk-Jae Chang; Victor Cheng; Kavitha M Chinnaiyan; Benjamin Chow; Augustin Delago; Martin Hadamitzky; Jorg Hausleiter; Ronald P Karlsberg; Philipp Kaufmann; Erica Maffei; Khurram Nasir; Michael J Pencina; Gilbert L Raff; Leslee J Shaw; Todd C Villines Journal: J Cardiovasc Comput Tomogr Date: 2011-02-01
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