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
Cardiac

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

Keywords

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

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

Notes

Acknowledgments

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.

References

  1. 1.
    Mark DB, Berman DS, Budoff MJ et al (2010) ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol 55:2663–2699PubMedCrossRefGoogle Scholar
  2. 2.
    Leber AW, Johnson T, Becker A et al (2007) Diagnostic accuracy of dual-source multi-slice CT-coronary angiography in patients with an intermediate pretest likelihood for coronary artery disease. Eur Heart J 28:2354–2360PubMedCrossRefGoogle Scholar
  3. 3.
    Meijboom WB, van Mieghem CA, Mollet NR et al (2007) 64-slice computed tomography coronary angiography in patients with high, intermediate, or low pretest probability of significant coronary artery disease. J Am Coll Cardiol 50:1469–1475PubMedCrossRefGoogle Scholar
  4. 4.
    Weustink AC, Mollet NR, Neefjes LA et al (2010) Diagnostic accuracy and clinical utility of noninvasive testing for coronary artery disease. Ann Intern Med 152:630–639PubMedCrossRefGoogle Scholar
  5. 5.
    Brenner DJ, Hall EJ (2007) Computed tomography—an increasing source of radiation exposure. N Engl J Med 357:2277–2284PubMedCrossRefGoogle Scholar
  6. 6.
    Einstein AJ, Moser KW, Thompson RC, Cerqueira MD, Henzlova MJ (2007) Radiation dose to patients from cardiac diagnostic imaging. Circulation 116:1290–1305PubMedCrossRefGoogle Scholar
  7. 7.
    Shaw LJ, Hachamovitch R, Berman DS et al (1999) The economic consequences of available diagnostic and prognostic strategies for the evaluation of stable angina patients: an observational assessment of the value of precatheterization ischemia. Economics of Noninvasive Diagnosis (END) Multicenter Study Group. J Am Coll Cardiol 33:661–669PubMedCrossRefGoogle Scholar
  8. 8.
    Diamond GA, Forrester JS (1979) Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 300:1350–1358PubMedCrossRefGoogle Scholar
  9. 9.
    Pryor DB, Shaw L, McCants CB et al (1993) Value of the history and physical in identifying patients at increased risk for coronary artery disease. Ann Intern Med 118:81–90PubMedCrossRefGoogle Scholar
  10. 10.
    Morise AP, Haddad WJ, Beckner D (1997) Development and validation of a clinical score to estimate the probability of coronary artery disease in men and women presenting with suspected coronary disease. Am J Med 102:350–356PubMedCrossRefGoogle Scholar
  11. 11.
    Fox K, Garcia MA, Ardissino D et al (2006) Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J 27:1341–1381PubMedCrossRefGoogle Scholar
  12. 12.
    Taylor AJ, Cerqueira M, Hodgson JM et al (2010) ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 56:1864–1894PubMedCrossRefGoogle Scholar
  13. 13.
    Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R (1990) Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 15:827–832PubMedCrossRefGoogle Scholar
  14. 14.
    Rumberger JA, Simons DB, Fitzpatrick LA, Sheedy PF, Schwartz RS (1995) Coronary artery calcium area by electron-beam computed tomography and coronary atherosclerotic plaque area. A histopathologic correlative study. Circulation 92:2157–2162PubMedCrossRefGoogle Scholar
  15. 15.
    Leschka S, Scheffel H, Desbiolles L et al (2008) Combining dual-source computed tomography coronary angiography and calcium scoring: added value for the assessment of coronary artery disease. Heart 94:1154–1161PubMedCrossRefGoogle Scholar
  16. 16.
    Kennedy J, Shavelle R, Wang S, Budoff M, Detrano RC (1998) Coronary calcium and standard risk factors in symptomatic patients referred for coronary angiography. Am Heart J 135:696–702PubMedCrossRefGoogle Scholar
  17. 17.
    Budoff MJ, Diamond GA, Raggi P et al (2002) Continuous probabilistic prediction of angiographically significant coronary artery disease using electron beam tomography. Circulation 105:1791–1796PubMedCrossRefGoogle Scholar
  18. 18.
    Guerci AD, Spadaro LA, Goodman KJ et al (1998) Comparison of electron beam computed tomography scanning and conventional risk factor assessment for the prediction of angiographic coronary artery disease. J Am Coll Cardiol 32:673–679PubMedCrossRefGoogle Scholar
  19. 19.
    Haberl R, Becker A, Leber A et al (2001) Correlation of coronary calcification and angiographically documented stenoses in patients with suspected coronary artery disease: results of 1,764 patients. J Am Coll Cardiol 37:451–457PubMedCrossRefGoogle Scholar
  20. 20.
    Genders TS, Pugliese F, Mollet NR et al (2010) Incremental value of the CT coronary calcium score for the prediction of coronary artery disease. Eur Radiol 20:2331–2340PubMedCrossRefGoogle Scholar
  21. 21.
    Genders TS, Steyerberg EW, Hunink MG et al (2012) Prediction model to estimate presence of coronary artery disease: retrospective pooled analysis of existing cohorts. BMJ 344:e3485PubMedCrossRefGoogle Scholar
  22. 22.
    Cheng VY, Berman DS, Rozanski A et al (2011) Performance of the traditional age, sex, and angina typicality-based approach for estimating pretest probability of angiographically significant coronary artery disease in patients undergoing coronary computed tomographic angiography: Results from the Multinational Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry (CONFIRM). Circulation 124:2423–2432PubMedCrossRefGoogle Scholar
  23. 23.
    Villines TC, Hulten EA, Shaw LJ et al (2011) Prevalence and severity of coronary artery disease and adverse events among symptomatic patients with coronary artery calcification scores of zero undergoing coronary computed tomography angiography: results from the CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter) registry. J Am Coll Cardiol 58:2533–2540PubMedCrossRefGoogle Scholar
  24. 24.
    Meijboom WB, Van Mieghem CA, van Pelt N et al (2008) Comprehensive assessment of coronary artery stenoses: computed tomography coronary angiography versus conventional coronary angiography and correlation with fractional flow reserve in patients with stable angina. J Am Coll Cardiol 52:636–643PubMedCrossRefGoogle Scholar
  25. 25.
    Weustink AC, Mollet NR, Neefjes LA et al (2009) Preserved diagnostic performance of dual-source CT coronary angiography with reduced radiation exposure and cancer risk. Radiology 252:53–60PubMedCrossRefGoogle Scholar
  26. 26.
    Dharampal AS, Rossi A, Papadopoulou SL et al (2011) Is there a difference in the diagnostic accuracy of computed tomography coronary angiography between women and men? Coron Artery Dis 22:421–427PubMedCrossRefGoogle Scholar
  27. 27.
    Dharampal AS, Papadopoulou SL, Rossi A et al (2012) Computed tomography coronary angiography accuracy in women and men at low to intermediate risk of coronary artery disease. Eur Radiol 22:2415–2423PubMedCrossRefGoogle Scholar
  28. 28.
    Nieman K, Galema T, Weustink A et al (2009) Computed tomography versus exercise electrocardiography in patients with stable chest complaints: real-world experiences from a fast-track chest pain clinic. Heart 95:1669–1675PubMedCrossRefGoogle Scholar
  29. 29.
    Diamond GA (1983) A clinically relevant classification of chest discomfort. J Am Coll Cardiol 1:574–575PubMedCrossRefGoogle Scholar
  30. 30.
    Maisel AS, Ahnve S, Gilpin E et al (1985) Prognosis after extension of myocardial infarct: the role of Q wave or non-Q wave infarction. Circulation 71:211–217PubMedCrossRefGoogle Scholar
  31. 31.
    Austen WG, Edwards JE, Frye RL et al (1975) A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation 51:5–40PubMedCrossRefGoogle Scholar
  32. 32.
    Hosmer DW, Hosmer T, Le Cessie S, Lemeshow S (1997) A comparison of goodness-of-fit tests for the logistic regression model. Stat Med 16:965–980PubMedCrossRefGoogle Scholar
  33. 33.
    DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44:837–845PubMedCrossRefGoogle Scholar
  34. 34.
    Cook NR, Ridker PM (2009) Advances in measuring the effect of individual predictors of cardiovascular risk: the role of reclassification measures. Ann Intern Med 150:795–802PubMedCrossRefGoogle Scholar
  35. 35.
    Wijns W, Kolh P, Danchin N et al (2010) Guidelines on myocardial revascularization. Eur Heart J 31:2501–2555PubMedCrossRefGoogle Scholar
  36. 36.
    De Bruyne B, Pijls NH, Kalesan B et al (2012) Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 367:991–1001PubMedCrossRefGoogle Scholar
  37. 37.
    Genders TS, Steyerberg EW, Alkadhi H et al (2011) A clinical prediction rule for the diagnosis of coronary artery disease: validation, updating, and extension. Eur Heart J 32:1316–1330PubMedCrossRefGoogle Scholar
  38. 38.
    Arbab-Zadeh A, Miller JM, Rochitte CE et al (2012) Diagnostic accuracy of computed tomography coronary angiography according to pre-test probability of coronary artery disease and severity of coronary arterial calcification. The CORE-64 (Coronary Artery Evaluation Using 64-Row Multidetector Computed Tomography Angiography) International Multicenter Study. J Am Coll Cardiol 59:379–387PubMedCrossRefGoogle Scholar

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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