European Radiology

, Volume 23, Issue 10, pp 2676–2686 | Cite as

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

  • Anoeshka S. Dharampal
  • Alexia Rossi
  • Admir Dedic
  • Filippo Cademartiri
  • Stella L. Papadopoulou
  • Annick C. Weustink
  • Bart S. Ferket
  • Eric Boersma
  • Willem B. Meijboom
  • Tjebbe W. Galema
  • Koen Nieman
  • Pim J. de Feyter
  • Gabriel P. Krestin



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).


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).


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 %.


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


Coronary artery disease (CAD) Clinical evaluation Calcium score (CaSc) Computed tomography coronary angiography (CTCA) Reclassification 



angina pectoris


area under the receiver-operating characteristic curve


coronary artery disease


calcium score


confidence interval


computed tomography coronary angiography


cardiovascular disease


dose length product




pathological Q-wave on ECG


invasive coronary angiography


interquartile range


net reclassification improvement


odds ratio


standard deviation


standard error



Parts of this single-centre cardiac database have been used in previous studies [4, 24, 25, 26, 27, 28].

Competing interest statement

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


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Copyright information

© European Society of Radiology 2013

Authors and Affiliations

  • Anoeshka S. Dharampal
    • 1
    • 2
  • Alexia Rossi
    • 1
    • 2
  • Admir Dedic
    • 1
    • 2
  • Filippo Cademartiri
    • 1
    • 4
  • Stella L. Papadopoulou
    • 1
    • 2
  • Annick C. Weustink
    • 1
    • 2
  • Bart S. Ferket
    • 1
    • 3
  • Eric Boersma
    • 2
  • Willem B. Meijboom
    • 1
    • 2
  • Tjebbe W. Galema
    • 2
  • Koen Nieman
    • 1
    • 2
  • Pim J. de Feyter
    • 1
    • 2
  • Gabriel P. Krestin
    • 1
  1. 1.Erasmus MC Department of RadiologyRotterdamThe Netherlands
  2. 2.Erasmus MC Department of CardiologyRotterdamThe Netherlands
  3. 3.Erasmus MC Department of EpidemiologyRotterdamThe Netherlands
  4. 4.Giovanni XXIII Hospital, Department of RadiologyMonastier di TrevisoItaly

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