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Restriction of the referral of patients with stable angina for CT coronary angiography by clinical evaluation and calcium score: impact on clinical decision making

  • Cardiac
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Abstract

Objective

To investigate the value of the calcium score (CaSc) plus clinical evaluation to restrict referral for CT coronary angiography (CTCA) by reducing the number of patients with an intermediate probability of coronary artery disease (CAD).

Methods

We retrospectively included 1,975 symptomatic stable patients who underwent clinical evaluation and CaSc calculation and CTCA or invasive coronary coronary angiography (ICA). The outcome was obstructive CAD (≥50 % diameter narrowing) assessed by ICA or CTCA in the absence of ICA. We investigated two models: (1) clinical evaluation consisting of chest pain typicality, gender, age, risk factors and ECG and (2) clinical evaluation with CaSc. Discrimination of the two models was compared. The stepwise reclassification of patients with an intermediate probability of CAD (10–90 %) after clinical evaluation followed by clinical evaluation with CaSc was assessed by clinical net reclassification improvement (NRI).

Results

Discrimination of CAD was significantly improved by adding CaSc to the clinical evaluation (AUC: 0.80 vs. 0.89, P < 0.001). CaSc and CTCA could be avoided in 9 % using model 1 and an additional 29 % of CTCAs could be avoided using model 2. Clinical NRI was 57 %.

Conclusion

CaSc plus clinical evaluation may be useful in restricting further referral for CTCA by 38 % in symptomatic stable patients with suspected CAD.

Key Points

CT calcium scores (CaSc) could proiritise referrals for CT coronary angiography (CTCA)

CaSc provides an incremental discriminatory value of CAD compared with clinical evaluation

Risk stratification is better when clinical evaluation is combined with CaSc

Appropriate use of clinical evaluation and CaSc helps avoid unnecessary CTCA referrals

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Abbreviations

AP:

angina pectoris

AUC:

area under the receiver-operating characteristic curve

CAD:

coronary artery disease

CaSc:

calcium score

CI:

confidence interval

CTCA:

computed tomography coronary angiography

CVD:

cardiovascular disease

DLP:

dose length product

ECG:

electrocardiogram

ECGQ:

pathological Q-wave on ECG

ICA:

invasive coronary angiography

IQR:

interquartile range

NRI:

net reclassification improvement

OR:

odds ratio

SD:

standard deviation

SE:

standard error

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Acknowledgments

Parts of this single-centre cardiac database have been used in previous studies [4, 2428].

Competing interest statement

There is no financial interest involved in this manuscript, and there are no conflicts of interest.

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Correspondence to Anoeshka S. Dharampal.

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Dharampal, A.S., Rossi, A., Dedic, A. et al. Restriction of the referral of patients with stable angina for CT coronary angiography by clinical evaluation and calcium score: impact on clinical decision making. Eur Radiol 23, 2676–2686 (2013). https://doi.org/10.1007/s00330-013-2898-7

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