Incremental value of stress echocardiography and computed tomography coronary calcium scoring for the diagnosis of coronary artery disease

  • Wael AlJaroudi
  • Mohamad Jihad Mansour
  • Maroun Chedid
  • Omar Hamoui
  • Joseph Asmar
  • Layal Mansour
  • Elie ChammasEmail author
Original Paper


Computed tomography coronary angiography (CTCA) has a higher negative predictive value (NPV) for coronary artery disease (CAD) than stress echocardiography (SE). CT calcium scoring (CTCS) allows detection and quantification of coronary artery calcification (CAC). The NPV of combined SE and CTCS for CAD is not well defined. Consecutive patients from the executive screening program who underwent exercise SE and concomitant CTCA were retrospectively identified between January 2010 and December 2014. Patients with normal SE and CAC score of zero were determined, and the presence or absence of any CAD (obstructive or non-obstructive plaques) on CTCA was confirmed. The NPV of combined SE and CTCS was then re-tested using a validation cohort of subsequent consecutive patients enrolled between January 2015 and July 2018. The initial cohort consisted of 173 patients (19% age > 65 years, 19% diabetic); 40% had normal CTCA, 48% with non-obstructive CTCA (77 with CAC score > 0), and 12% with obstructive CTCA (all with CAC score > 0). There were 16 (9.2%) patients with inducible ischemia on SE. A normal SE had a 93% NPV to exclude obstructive CAD but only 42% NPV to exclude any CAD. A combined normal SE and CTCS had a 100% NPV for obstructive CAD, and 92% for any CAD. In a validation cohort of 111 patients, a normal SE and CAC score of zero had NPV of 100% for obstructive CAD and 92% for any CAD. The combined cohort consisted of predominately low Framingham risk patients; more than 40% (70/181) had CAC score > 0 and 5/70 had obstructive CAD, with the remaining non-obstructive. A concomitant normal SE and CAC score of zero excluded obstructive CAD (NPV 100%) and any CAD in 92% of the testing and validation cohorts. CTCS seems to add incremental risk stratification, particularly for patients with low Framingham score.


Stress echocardiography Computed tomography coronary angiography Coronary artery disease Coronary artery calcium score 



Coronary artery calcification/calcium


Coronary artery disease


Computed tomography coronary angiography


Computed tomography calcium scoring




Framingham risk score


Heart rate


Major adverse cardiovascular events


Negative predictive value


Positive predictive value


Stress echocardiography


Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.


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Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  • Wael AlJaroudi
    • 1
  • Mohamad Jihad Mansour
    • 1
    • 2
  • Maroun Chedid
    • 3
  • Omar Hamoui
    • 1
  • Joseph Asmar
    • 2
  • Layal Mansour
    • 3
  • Elie Chammas
    • 1
    • 2
    Email author
  1. 1.Division of Cardiovascular MedicineClemenceau Medical CenterBeirutLebanon
  2. 2.Division of Cardiology, Faculty of Medical SciencesLebanese UniversityHadathLebanon
  3. 3.Department of Internal Medicine, Faculty of Medical SciencesLebanese UniversityHadathLebanon

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