The Absence of Coronary Calcification Does Not Exclude Obstructive Coronary Artery Disease or the Need for Revascularization in Patients Referred for Conventional Coronary Angiography

J Am Coll Cardiol. 2010; 44(2):627-634

Ilan Gottlieb,, Julie M. Miller, Armin Arbab-Zadeh, Marc Dewey, Melvin E. Clouse, Leonardo Sara, Hiroyuki Niinuma, David E. Bush, Narinder Paul, Andrea L. Vavere, John Texter, Jeffery Brinker, João A.C. Lima, Carlos E. Rochitte

OBJECTIVES: This study was designed to evaluate whether the absence of coronary calcium could rule out ≥50% coronary stenosis or the need for revascularization. The latest American Heart Association guidelines suggest that a calcium score (CS) of zero might exclude the need for coronary angiography among symptomatic patients.

METHODS: A substudy was made of the CORE64 (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors) multicenter trial comparing the diagnostic performance of 64-detector computed tomography to conventional angiography. Patients clinically referred for conventional angiography were asked to undergo a CS scan up to 30 days before.

RESULTS: In all, 291 patients were included, of whom 214 (73%) were male, and the mean age was 59.3 ± 10.0 years. A total of 14 (5%) patients had low, 218 (75%) had intermediate, and 59 (20%) had high pre-test probability of obstructive coronary artery disease. The overall prevalence of ≥50% stenosis was 56%. A total of 72 patients had CS = 0, among whom 14 (19%) had at least 1 ≥50% stenosis. The overall sensitivity for CS = 0 to predict the absence of ≥50% stenosis was 45%, specificity was 91%, negative predictive value was 68%, and positive predictive value was 81%. Additionally, revascularization was performed in 9 (12.5%) CS = 0 patients within 30 days of the CS. From a total of 383 vessels without any coronary calcification, 47 (12%) presented with ≥50% stenosis; and from a total of 64 totally occluded vessels, 13 (20%) had no calcium.

CONCLUSIONS: The absence of coronary calcification does not exclude obstructive stenosis or the need for revascularization among patients with high enough suspicion of coronary artery disease to be referred for coronary angiography, in contrast with the published recommendations. Total coronary occlusion frequently occurs in the absence of any detectable calcification. (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors [CORE-64]; NCT00738218)

PMID:

3 Responses

  1. Paul Schoenhagen, MD  on February 8th, 2010

    Check comments at:
    Zero means nothing: “Gatekeeper” role of calcium scoring questioned
    Reed Miller
    HeartWire; February 8, 2010

  2. Ronen Rubinshtein, MD  on February 9th, 2010

    Also see:
    Zero or Low Agatston Calcium Score Does Not Exclude Significant Coronary Stenosis in Symptomatic Patients Undergoing 64-Slice Cardiac Computed Tomography.
    Ronen Rubinshtein; David A Halon; Tamar Gaspar; Jorge E Schliamser; Jacob Goldstein; Basheer Karkabi; Moshe Y Flugelman; Nathan Peled; Basil S Lewis.
    Am J Cardiol 2007;99:472-5.
    Abstract 3824

    Not all plaques are calcified. Theoretically, calcified lesions are “not new”.
    However, our ability to differentiate acute from chronic symptoms is limited. (e.g. many healthy subjects or “stable patients” in the PEACE trial had elevated level of sensitive cardiac Troponins which was in association with outcome

    A Sensitive Cardiac Troponin T Assay in Stable Coronary Artery Disease
    Torbjørn Omland, M.D., Ph.D., M.P.H., James A. de Lemos, M.D., Marc S. Sabatine, M.D., M.P.H., Costas A. Christophi, Ph.D., Madeline Murguia Rice, Ph.D., Kathleen A. Jablonski, Ph.D., Solve Tjora, M.D., Michael J. Domanski, M.D., Bernard J. Gersh, M.B., Ch.B., D.Phil., Jean L. Rouleau, M.D., Marc A. Pfeffer, M.D., Ph.D., Eugene Braunwald, M.D.,
    N Eng J Med 2009; 361:2538-47.

  3. Jacobo Kirsch, MD  on February 9th, 2010

    This study concentrates on symptomatic patients scheduled to undergo clinically indicated conventional angiography, and that should be the take-home point from the study. It is not reasonable to transfer this knowledge to other groups and further studies with mixed-risk populations are warranted.
    In the meantime, rather than using CCS as a tool to exclude CAD in symptomatic patients, it’s capacity to detect the presence CAD in low and intermediate risk patients continues to have clinical value.


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