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

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Abstract

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.

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Abbreviations

CAC:

Coronary artery calcification/calcium

CAD:

Coronary artery disease

CTCA:

Computed tomography coronary angiography

CTCS:

Computed tomography calcium scoring

ECG:

Electrocardiogram

FRS:

Framingham risk score

HR:

Heart rate

MACE:

Major adverse cardiovascular events

NPV:

Negative predictive value

PPV:

Positive predictive value

SE:

Stress echocardiography

References

  1. Budoff MJ, Mayrhofer T, Ferencik M, Bittner D, Lee KL, Lu MT et al (2017) Prognostic value of coronary artery calcium in the PROMISE study (prospective multicenter imaging study for evaluation of chest pain). Circulation 136(21):1993–2005

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  2. Neglia D, Rovai D, Caselli C, Pietila M, Teresinska A, Aguade-Bruix S et al (2015) Detection of significant coronary artery disease by noninvasive anatomical and functional imaging. Circ Cardiovasc Imaging 8:e002179

    Article  PubMed  Google Scholar 

  3. Doris M, Newby DE (2016) How should CT coronary angiography be integrated into the management of patients with chest pain and how does this affect outcomes? Eur Heart J Qual Care Clin Outcomes 2(2):72–80

    Article  PubMed  Google Scholar 

  4. Budoff MJ, Shaw LJ, Liu ST, Weinstein SR, Mosler TP, Tseng PH et al (2007) Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol 49:1860–1870

    Article  PubMed  Google Scholar 

  5. Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB (1998) Prediction of coronary heart disease using risk factor categories. Circulation 97:1837–1847

    Article  PubMed  CAS  Google Scholar 

  6. Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB, Gibbons R Sr et al (2014) 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 63:2935–2959 ;(25 Pt B)

    Article  PubMed  Google Scholar 

  7. Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA et al (2010) 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 56(25):e50–e103

    Article  PubMed  Google Scholar 

  8. Mansour MJ, Aljaroudi W, Mroueh A, Hamoui O, Honeine W, Khoury N et al (2017) Stress-induced worsening of left ventricular diastolic function as a marker of myocardial ischemia. J Cardiovasc Echogr 27:45–51

    Article  PubMed  PubMed Central  Google Scholar 

  9. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 16:233–237

    Article  PubMed  Google Scholar 

  10. Pellikka PA, Nagueh SF, Elhendy AA, Kuehl CA, Sawada SG, American Society of Echocardiography et al (2007) American society of echocardiography recommendations for performance, interpretation, and application of stress echocardiography. J Am Soc Echocardiogr 20:1021–1041

    Article  PubMed  Google Scholar 

  11. Mark DB, Shaw L, Harrell FE Jr, Hlatky MA, Lee KL, Bengtson JR et al (1991) Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 325(12):849–853

    Article  PubMed  CAS  Google Scholar 

  12. Gibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF, Froelicher VF et al (1997) ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Circulation 96(1):345–354

    Article  PubMed  CAS  Google Scholar 

  13. Abbara S, Blanke P, Maroules CD, Cheezum M, Choi AD, Han BK (2016) SCCT guidelines for the performance and acquisition of coronary computed tomographic angiography: A report of the society of Cardiovascular Computed Tomography Guidelines Committee: Endorsed by the North American Society for Cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr 10(6):435–449

    Article  PubMed  Google Scholar 

  14. Schroeder S, Achenbach S, Bengel F, Burgstahler C, Cademartiri F, de Feyter P et al (2008) Cardiac computed tomography: indications, applications, limitations, and training requirements: report of a writing group deployed by the Working Group Nuclear Cardiology and Cardiac CT of the European Society of Cardiology and the European Council of Nuclear Cardiology. Eur Heart J 29:531–556

    Article  PubMed  Google Scholar 

  15. Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R et al (1990) Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 15(4):827–832

    Article  PubMed  CAS  Google Scholar 

  16. Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al (2012) 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 60(24):e44

    Article  PubMed  Google Scholar 

  17. Nappi C, Nicolai E, Daniele S, Acampa W, Gaudieri V, Assante R et al (2018) Long-term prognostic value of coronary artery calcium scanning, coronary computed tomographic angiography and stress myocardial perfusion imaging in patients with suspected coronary artery disease. J Nucl Cardiol 25:833–841

    Article  PubMed  Google Scholar 

  18. van Waardhuizen CN, Khanji MY, Genders TSS, Ferket BS, Fleischmann KE, Hunink MGM et al (2016) Comparative cost-effectiveness of non-invasive imaging tests in patients presenting with chronic stable chest pain with suspected coronary artery disease: a systematic review. Eur Heart J Qual Care Clin Outcomes 2(4):245–260

    Article  PubMed  Google Scholar 

  19. Greenland P, Blaha MJ, Budoff MJ, Erbel R, Watson KE (2018) Coronary calcium score and cardiovascular risk. J Am Coll Cardiol 72(4):434–447

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  20. Berman DS, Wong ND, Gransar H et al (2004) Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography. J Am Coll Cardiol 44:923–930

    Article  PubMed  CAS  Google Scholar 

  21. Newby DE (2015) The SCOT-HEART investigators. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open label, parallel-group, multicenter trial. Lancet 385:2383–2391

    Article  Google Scholar 

  22. Lakoski SG, Greenland P, Wong ND, Schreiner PJ, Herrington DM, Kronmal RA et al (2007) Coronary artery calcium scores and risk for cardiovascular events in women classified as “low risk” based on Framingham risk score: the multi-ethnic study of atherosclerosis (MESA). Arch Intern Med 167(22):2437–2442

    Article  PubMed  Google Scholar 

  23. Nasir K, Redberg RF, Budoff MJ, Hui E, Post WS, Blumenthal RS (2004) Utility of stress testing and coronary calcification measurement for detection of coronary artery disease in women. Arch Intern Med 164(15):1610–1620

    Article  PubMed  Google Scholar 

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Author notes

  1. Wael AlJaroudi and Mohamad Jihad Mansour contributed equally and are joint first authors.

Authors and Affiliations

  1. Division of Cardiovascular Medicine, Clemenceau Medical Center, PO BOX 11-2555, Beirut, Lebanon

    Wael AlJaroudi, Mohamad Jihad Mansour, Omar Hamoui & Elie Chammas

  2. Division of Cardiology, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon

    Mohamad Jihad Mansour, Joseph Asmar & Elie Chammas

  3. Department of Internal Medicine, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon

    Maroun Chedid & Layal Mansour

Authors
  1. Wael AlJaroudi
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  2. Mohamad Jihad Mansour
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  3. Maroun Chedid
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  4. Omar Hamoui
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  5. Joseph Asmar
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  6. Layal Mansour
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Correspondence to Elie Chammas.

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AlJaroudi, W., Mansour, M.J., Chedid, M. et al. Incremental value of stress echocardiography and computed tomography coronary calcium scoring for the diagnosis of coronary artery disease. Int J Cardiovasc Imaging 35, 1133–1139 (2019). https://doi.org/10.1007/s10554-019-01577-x

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  • DOI: https://doi.org/10.1007/s10554-019-01577-x

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