Title

Point of Care Clinical Risk Score to Improve the Negative Diagnostic Utility of an Agatston Score of Zero: Averting the Need for Coronary Computed Tomography Angiography

Authors

Ali M. Alshahrani, University of Ottawa Heart Institute
Hamza Mahmood, University of Ottawa Heart Institute
George A. Wells, University of Ottawa Heart Institute
Alomgir Hossain, University of Ottawa Heart Institute
Frank J. Rybicki, Ottawa Hospital Research Institute
Stephan Achenbach, Friedrich-Alexander-Universität Erlangen-Nürnberg
Mouaz H. Al-Mallah, Methodist Hospital Houston
Daniele Andreini, Università degli Studi di Milano
Jeroen J. Bax, Leiden University Medical Center - LUMC
Daniel S. Berman, Cedars-Sinai Medical Center
Matthew J. Budoff, The Lundquist Institute
Filippo Cademartiri, IRCCS Fondazione SDN
Tracy Q. Callister, Tennessee Heart and Vascular Institute
Hyuk Jae Chang, Yonsei University College of Medicine
Kavitha Chinnaiyan, William Beaumont Hospital
Ricardo C. Cury, Baptist Cardiac and Vascular Institute
Augustin Delago, Capitol Cardiology Associates
Gudrun Feuchtner, Medizinische Universitat Innsbruck
Martin Hadamitzky, Deutsches Herzzentrum München
Joerg Hausleiter, Ludwig-Maximilians-Universität München
Philipp A. Kaufmann, UniversitatsSpital Zurich
Yong Jin Kim, Seoul National University Hospital
Jonathon A. Leipsic, The University of British Columbia
Erica Maffei
Hugo Marques, Hospital da Luz
Gianluca Pontone, Università degli Studi di Milano
Gilbert Raff, William Beaumont Hospital
Ronen Rubinshtein, Technion - Israel Institute of Technology
Leslee J. Shaw, New York Presbyterian Hospital
Todd C. Villines, Walter Reed National Military Medical Center
Fay Y. Lin, New York Presbyterian Hospital
James K. Min, New York Presbyterian Hospital
Benjamin J. Chow, University of Ottawa Heart Institute

Document Type

Article

Publication Date

9-1-2019

Publication Title

Circulation: Cardiovascular Imaging

Abstract

© 2019 American Heart Association, Inc. Background: Coronary artery calcification is a marker of underlying atherosclerotic vascular disease. The absence of coronary artery calcification is associated with a low prevalence of obstructive coronary artery disease (CAD), but it cannot be ruled out completely. We sought to develop a clinical tool that can be added to Agatston score of zero to rule out obstructive CAD with high accuracy. Methods: We developed a clinical score retrospectively from a cohort of 4903 consecutive patients with an Agatston score of zero. Patients with prior diagnosis of CAD, coronary percutaneous coronary intervention, or surgical revascularization were excluded. Obstructive CAD was defined as any epicardial vessel diameter narrowing of ≥50%. The score was validated using an external cohort of 4290 patients with an Agatston score of zero from a multinational registry. Results: The score consisted of 7 variables: Age, sex, typical chest pain, dyslipidemia, hypertension, family history, and diabetes mellitus. The model was robust with an area under the curve of 0.70 (95% CI, 0.65-0.76) in the derivation cohort and 0.69 (95% CI, 0.65-0.72) in the validation cohort. Patients were divided into 3 risk groups based on the score: low (≤6), intermediate (7-13), and high (≥14). Patients who score ≤6 have a negative likelihood ratio of 0.42 for obstructive CAD, whereas those who score ≥14 have a positive likelihood ratio of >5.5 for obstructive CAD. The outcome was ruled out in >98% of patients with a score ≤6 in the validation cohort. Conclusions: We developed a score that may be used to identify the likelihood of obstructive CAD in patients with an Agatston score of zero, which may be used to direct the need for additional testing. However, the results of this retrospective analysis are hypothesis generating and before clinical implementation should be validated in a trial with a prospectively collected data.

Volume

12

Issue

9

DOI

10.1161/CIRCIMAGING.118.008737

ISSN

19419651

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