Log in to MyACC
Prognostic Value of Calcium Score of Zero for Chest Pain
Quick Takes
- A coronary artery calcium (CAC) score of zero in patients with stable or acute chest pain (CP) is associated with a low prevalence of coronary artery disease (CAD) and a low risk of major adverse cardiac events.
- The absence of CAC in low-to-intermediate risk patients with stable or acute CP potentially could be individuals that may not need subsequent testing.
Study Questions:
Can the absence of coronary artery calcium (CAC) in patients with stable or acute chest pain (CP) identify individuals who do not need subsequent downstream testing?
Methods:
This meta-analysis and systematic review evaluated the clinical value of a CAC score of zero in low-to-intermediate risk patients with stable or acute CP undergoing coronary computed tomography (CT) angiography. The accuracy of a CAC score of zero to identify patients with no coronary artery disease (CAD) or nonobstructive CAD and the prognostic value of this finding were examined. Patients with laboratory or electrocardiogram findings concerning for myocardial infarction were excluded from these studies. Major adverse events included acute coronary syndromes, revascularization, and all-cause mortality.
Results:
This meta-analysis included 19 papers (79,903 patients) evaluating individuals with predominantly stable CP and 13 papers (including 12,376 patients) of individuals with predominantly acute CP. A CAC score of zero was observed in 45% of patients with stable CP and 58% of patients with acute CP. In patients with a CAC score of zero, nonobstructive and obstructive CAD were seen in 13% and 3% of patients with stable CP, and 9% and 4% of patients with acute CP, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of a CAC score of zero to identify patients with obstructive CAD were 92%, 54%, 31%, and 97% for stable CP; and 90%, 67%, 32%, and 98% for acute CP, respectively. Annualized major adverse cardiac events in patients with a CAC score of zero (vs. >0) were 0.5% (vs. 2.2%) in patients with stable CP and 0.8% (vs. 8.5%) in patients with acute CP.
Conclusions:
Patients with stable or acute CP undergoing coronary CT angiography who have a CAC score of zero have low rates of CAD and adverse events. The absence of CAC in low-to-intermediate risk patients could potentially identify individuals that may not need subsequent testing.
Perspective:
This study supports existing literature observing the clinical value of a CAC score of zero. Patients with no CAC have low rates of both nonobstructive and obstructive CAD and have low rates of adverse events. However, a major limitation of this study is that all patients underwent coronary CT angiography with a CAC score, and these findings could have impacted patient management. For example, a patient with a CAC score of zero and obstructive CAD may have had management changes that could have impacted outcomes and in part explain the low rate of adverse events seen in these patients. Future study is needed to determine whether outcomes based on CAC testing alone are clinically safe and effective. It is worth pointing out that some patients with stable (16%) or acute (13%) CP and no CAC had obstructive or nonobstructive CAD, and testing with CAC alone would have missed patients that could benefit from management changes.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Angiography, Atherosclerosis, Chest Pain, Computed Tomography Angiography, Coronary Artery Disease, Diagnostic Imaging, Electrocardiography, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Plaque, Atherosclerotic, Risk, Secondary Prevention
< Back to Listings
