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Clerc OF, Frey SM, Honegger U, Amrein MLF, Caobelli F, Haaf P, Zellweger MJ. Coronary artery calcium score and pre-test probabilities as gatekeepers to predict and rule out perfusion defects in positron emission tomography. J Nucl Cardiol 2023; 30:2559-2573. [PMID: 37415007 PMCID: PMC10682222 DOI: 10.1007/s12350-023-03322-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/02/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Little is known about the gatekeeper performance of coronary artery calcium score (CACS) before myocardial perfusion positron emission tomography (PET), compared with updated pre-test probabilities from American and European guidelines (pre-test-AHA/ACC, pre-test-ESC). METHODS We enrolled participants without known coronary artery disease undergoing CACS and Rubidium-82 PET. Abnormal perfusion was defined as summed stress score ≥ 4. Using Bayes' formula, pre-test probabilities and CACS were combined into post-test probabilities. RESULTS We included 2050 participants (54% male, mean age 64.6 years) with median CACS 62 (IQR 0-380), pre-test-ESC 17% (11-26), pre-test-AHA/ACC 27% (16-44), and abnormal perfusion in 437 participants (21%). To predict abnormal perfusion, area under the curve of CACS was 0.81, pre-test-AHA/ACC 0.68, pre-test-ESC 0.69, post-test-AHA/ACC 0.80, and post-test-ESC 0.81 (P < 0.001 for CACS vs. each pre-test, and each post-test vs. pre-test). CACS = 0 had 97% negative predictive value (NPV), pre-test-AHA/ACC ≤ 5% 100%, pre-test-ESC ≤ 5% 98%, post-test-AHA/ACC ≤ 5% 98%, and post-test-ESC ≤ 5% 96%. Among participants, 26% had CACS = 0, 2% pre-test-AHA/ACC ≤ 5%, 7% pre-test-ESC ≤ 5%, 23% post-test-AHA/ACC ≤ 5%, and 33% post-test-ESC ≤ 5% (all P < 0.001). CONCLUSIONS CACS and post-test probabilities are excellent predictors of abnormal perfusion and can rule it out with very high NPV in a substantial proportion of participants. CACS and post-test probabilities may be used as gatekeepers before advanced imaging. Coronary artery calcium score (CACS) predicted abnormal perfusion (SSS ≥ 4) in myocardial positron emission tomography (PET) better than pre-test probabilities of coronary artery disease (CAD), while pre-test-AHA/ACC and pre-test-ESC performed similarly (left). Using Bayes' formula, pre-test-AHA/ACC or pre-test-ESC were combined with CACS into post-test probabilities (middle). This calculation reclassified a substantial proportion of participants to low probability of CAD (0-5%), not needing further imaging, as shown for AHA/ACC probabilities (2% with pre-test-AHA/ACC to 23% with post-test-AHA/ACC, P < 0.001, right). Very few participants with abnormal perfusion were classified under pre-test or post-test probabilities 0-5%, or under CACS 0. AUC: area under the curve. Pre-test-AHA/ACC: Pre-test probability of the American Heart Association/American College of Cardiology. Post-test-AHA/ACC: Post-test probability combining pre-test-AHA/ACC and CACS. Pre-test-ESC: Pre-test probability of the European Society of Cardiology. SSS: Summed stress score.
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Affiliation(s)
- Olivier F Clerc
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Simon M Frey
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ursina Honegger
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Melissa L F Amrein
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Federico Caobelli
- Department of Nuclear Medicine, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philip Haaf
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael J Zellweger
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.
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Rozanski A, Han D, Miller RJH, Gransar H, Slomka P, Hayes SW, Friedman JD, Thomson LEJ, Berman DS. Comparison of coronary artery calcium scores among patients referred for cardiac imaging tests. Prog Cardiovasc Dis 2023; 81:24-32. [PMID: 37858662 DOI: 10.1016/j.pcad.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 10/15/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND While coronary artery calcium (CAC) can now be evaluated by multiple imaging modalities, there is presently scant study regarding how CAC scores may vary among populations of varying clinical risk. METHODS We evaluated the distribution of CAC scores among three patient groups: 18,941 referred for CAC scanning, 5101 referred for diagnostic coronary CT angiography (CCTA), and 3307 referred for diagnostic positron emission tomography (PET) myocardial perfusion imaging (MPI). We assessed the relationship between CAC score and myocardial ischemia, obstructive coronary artery disease (CAD), and all-cause mortality across imaging modalities. RESULTS Within each age group, the frequency of CAC abnormalities were relatively similar across testing modalities, despite an annualized mortality rate which varied from 0.5%/year among CAC patients to 3.8%/year among PET-MPI patients (p < 0.001). Among CCTA and PET-MPI patients, a zero CAC score was common, occurring in ~70% of patients <50 years, ~40% of patients 50-59 years, and ~ 25% of patients 60-69 years. Among CCTA patients, zero CAC was associated with a normal coronary angiogram with high frequency, ranging from 92.2% among patients <50 years to 87.9% among patients ≥70 years. Among PET-MPI patients, zero CAC was associated with a very low frequency of inducible ischemia across all age groups, ranging from 1.5% among patients <50 years to 0.9% among patients ≥70 years. CONCLUSIONS In our study, relatively similar CAC scores were noted among patients varying markedly in mortality risk. Clinically, zero CAC scores predicted both a low likelihood of obstructive CAD and inducible myocardial ischemia in all age groups and were observed with high frequency across diagnostic testing modalities.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, the Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Donghee Han
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Robert J H Miller
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America; Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Heidi Gransar
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Piotr Slomka
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Sean W Hayes
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - John D Friedman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Louise E J Thomson
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Daniel S Berman
- Departments of Imaging and Medicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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3
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Benefit of Early Revascularization Based on Inducible Ischemia and Left Ventricular Ejection Fraction. J Am Coll Cardiol 2022; 80:202-215. [PMID: 35835493 DOI: 10.1016/j.jacc.2022.04.052] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/04/2022] [Accepted: 04/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND The utility of performing early myocardial revascularization among patients presenting with inducible myocardial ischemia and low left ventricular ejection fraction (LVEF) is currently unknown. OBJECTIVES In this study, we sought to assess the relationship between stress-induced myocardial ischemia, revascularization, and all-cause mortality (ACM) among patients with normal vs low LVEF. METHODS We evaluated 43,443 patients undergoing stress-rest single-photon emission computed tomography myocardial perfusion imaging from 1998 to 2017. Median follow-up was 11.4 years. Myocardial ischemia was assessed for its interaction between early revascularization and mortality. A propensity score was used to adjust for nonrandomization to revascularization, followed by multivariable Cox modeling adjusted for the propensity score and clinical variables to predict ACM. RESULTS The frequency of myocardial ischemia varied markedly according to LVEF and angina, ranging from 6.7% among patients with LVEF ≥55% and no typical angina to 64.0% among patients with LVEF <45% and typical angina (P < 0.001). Among 39,883 patients with LVEF ≥45%, early revascularization was associated with increased mortality risk among patients without ischemia and lower mortality risk among patients with severe (≥15%) ischemia (HR: 0.70; 95% CI: 0.52-0.95). Among 3,560 patients with LVEF <45%, revascularization was not associated with mortality benefit among patients with no or mild ischemia, and was associated with decreased mortality among patients with moderate (10%-14%) (HR: 0.67; 95% CI: 0.49-0.91) and severe (≥15%) (HR: 0.55; 95% CI: 0.38-0.80) ischemia. CONCLUSIONS Within this cohort, early myocardial revascularization was associated with a significant reduction in mortality among both patients with normal LVEF and severe inducible myocardial ischemia and patients with low LVEF and moderate or severe inducible myocardial ischemia.
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Mahmood T, Shapiro MD. Coronary artery calcium testing in low-intermediate risk symptomatic patients with suspected coronary artery disease: An effective gatekeeper to further testing? PLoS One 2020; 15:e0240539. [PMID: 33048982 PMCID: PMC7553353 DOI: 10.1371/journal.pone.0240539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Computed tomography for quantification of coronary artery calcium (CAC) is a simple non-invasive tool to assess atherosclerotic plaque burden. CAC is highly correlated with coronary atherosclerosis and is a robust predictor of cardiovascular outcomes. Recently, the 2018 ACC/AHA Cholesterol Guidelines endorsed the use of CAC scores in asymptomatic, intermediate risk individuals where the decision to initiate stain therapy is uncertain. However, whether quantification of CAC may play a role in the assessment of symptomatic individuals remains a matter of debate. In this review, we examine the evidence for the use of CAC in low-intermediate risk patients with chest pain. This appraisal places a particular focus on the growing body of literature supporting the negative predictive value of a CAC score of zero to rule out significant coronary artery disease in those without high-risk features. We also evaluate current guidelines, limitations, and future research directions for CAC scoring in this important subgroup of patients.
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Affiliation(s)
- Tahir Mahmood
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, United States of America
| | - Michael D. Shapiro
- Center for Prevention of Cardiovascular Disease, Section on Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, United States of America
- * E-mail:
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Murthy VL, Nasir K. Staged testing as a solution to the challenges of testing lower risk patients. J Nucl Cardiol 2020; 27:1497-1500. [PMID: 30225816 PMCID: PMC6421111 DOI: 10.1007/s12350-018-1437-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Venkatesh L Murthy
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Dr, SPC 5873, Ann Arbor, MI, 48109-5873, USA.
| | - Khurram Nasir
- Division of Cardiovascular Medicine, Center for Outcomes & Research Evaluation (CORE), Yale University School of Medicine & Yale New Haven Health, New Haven, CT, USA
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Shen YW, Wu YJ, Hung YC, Hsiao CC, Chan SH, Mar GY, Wu MT, Wu FZ. Natural course of coronary artery calcium progression in Asian population with an initial score of zero. BMC Cardiovasc Disord 2020; 20:212. [PMID: 32375648 PMCID: PMC7204036 DOI: 10.1186/s12872-020-01498-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 04/29/2020] [Indexed: 11/18/2022] Open
Abstract
Background We aimed to investigate the natural course of coronary artery calcium progression in an Asian population with a baseline coronary artery calcium (CAC) score of zero, and to determine subclinical coronary atherosclerosis. Methods Four hundred fifty-nine subjects with at least two CAC scans with an initial score of zero were included. CAC progression (+) was defined by the development of any CAC (i.e., CAC > 0) during subsequent CT scans. Clinical characteristics and Framingham risk profiles were also recorded. Results Among 459 subjects, 106 (23.09%) experienced CAC progression during the average follow-up period of 5.71 ± 2.68 years. Older age, male gender, HDL-C, total cholesterol and higher Framingham risk score were independently associated with CAC progression. Framingham risk score had the better discriminative ability (AUC = 0.660) to predict CAC progression compared to the other parameters with a sensitivity of 75.24% and specificity of 53.95%. For the double zero score with coronary artery atherosclerosis prediction, older age, triglycerides, hypertension, and Framingham risk score were significantly associated with these events. Among these parameters, Framingham risk score may be a relatively acceptable parameter with high negative predictive (NPV = 96.4%) value to rule out double zero score with obstructive coronary artery atherosclerosis scenario with an optimum cut-off value of <16.9 (AUC =0.652, sensitivity of 57.69%; specificity of 68.82%). Conclusions A baseline zero CAC score in asymptomatic Chinese population with low to intermediate risk have a low incidence for CAC progression within the 5-years period. For CAC progression prediction, Framingham risk score with the cutoff < 11.1 may help confirm subjects at low risk to improve cardiovascular risk stratification and reclassification in the field of preventive cardiology.
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Affiliation(s)
- Yi-Wen Shen
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Kaohsiung, Taiwan.,Department of Medical Imaging and Radiological Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yun-Ju Wu
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Kaohsiung, Taiwan
| | - Yi-Chi Hung
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Kaohsiung, Taiwan.,Department of Medical Imaging and Radiology, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
| | - Chia-Chi Hsiao
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Kaohsiung, Taiwan.,Department of Medical Imaging and Radiology, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
| | - Shan-Ho Chan
- Department of Medical Imaging and Radiology, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
| | - Guang-Yuan Mar
- Physical Examination Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ming-Ting Wu
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Kaohsiung, Taiwan.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Fu-Zong Wu
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Kaohsiung, Taiwan. .,Department of Medical Imaging and Radiology, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan. .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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AlJaroudi WA, Hage FG. Review of cardiovascular imaging in the Journal of Nuclear Cardiology 2017. Part 1 of 2: Positron emission tomography, computed tomography, and magnetic resonance. J Nucl Cardiol 2018; 25:320-330. [PMID: 29119374 DOI: 10.1007/s12350-017-1120-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 10/27/2017] [Indexed: 12/11/2022]
Abstract
Several original articles and editorials have been published in the Journal of Nuclear Cardiology in 2017. It has become a tradition at the beginning of each year to summarize some of these key articles in 2 sister reviews. In this first part one, we will discuss some of the progress made in the field of heart failure (cardio-oncology, myocardial blood flow, viability, dyssynchrony, and risk stratification), inflammation, molecular and hybrid imaging using advancement in positron emission tomography, computed tomography, and magnetic resonance imaging.
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Affiliation(s)
- Wael A AlJaroudi
- Division of Cardiovascular Medicine, Clemenceau Medical Center, Beirut, Lebanon
| | - Fadi G Hage
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 306 Lyons-Harrison Research Building, 701 19th Street South, Birmingham, AL, 35294-0007, USA.
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
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Rozanski A, Berman DS. Coronary artery calcium scanning in symptomatic patients: Ready for use as a gatekeeper for further testing? J Nucl Cardiol 2017; 24:835-838. [PMID: 28205074 DOI: 10.1007/s12350-017-0794-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 01/09/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Alan Rozanski
- Division of Cardiology, Mount Sinai St. Lukes Hospital, Mount Sinai Heart, 1111 Amsterdam Avenue, New York, NY, 10025, USA.
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Daniel S Berman
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center and the Cedars-Sinai Heart Institute, Los Angeles, CA, USA
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Harrington J, Mody P, Blankstein R, Nasir K, Blaha MJ, Joshi PH. Coronary Artery Calcium Testing in Patients with Chest Pain: Alive and Kicking. CURRENT CARDIOVASCULAR RISK REPORTS 2017. [DOI: 10.1007/s12170-017-0542-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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