Evaluation of Clinical Applicability of Coronary Artery Calcium Assessment on Non–Gated Chest Computed Tomography, Compared With the Classic Agatston Score on Cardiac Computed Tomography

Abstract

•Coronary artery calcium assessment on routine chest computed tomography in patients with stable chest pain.•Is a cost-free and radiation-free source of information on patients’ cardiac risk.•Has equal discriminative power for risk estimation of coronary artery calcium to that of cardiac directed computed tomography.•Can be used as an additional tool for clinical evaluation of patients with cardiac disease. Given current pretest probability (PTP) estimations tend to overestimate patients’ risk for obstructive coronary artery disease, evaluation of patients’ coronary artery calcium (CAC) is more precise. The value of CAC assessment with the Agatston score on cardiac computed tomography (CT) for risk estimation has been well indicated in patients with stable chest pain. CAC can be equally well assessed on routine non–gated chest CT, which is often available. This study aims to determine the clinical applicability of CAC assessment on non–gated CT in patients with stable chest pain compared with the classic Agatston score on gated CT. Consecutive patients referred for evaluation of the Agatston score, who had a previously performed non–gated chest CT for evaluation of noncardiac diseases, were included. CAC on non–gated CT was ordinally scored. Subsequently, patients were stratified according to CAC severity and PTP. The agreement and correlation between the classic Agatston score and CAC on non–gated CT were evaluated. The discriminative power for risk reclassification of both CAC assessment methods was assessed. Invasive coronary angiography was used as the gold standard, when available. A total of 140 patients aged between 30 and 88 years were included. The agreement between ordinally scored CAC and the Agatston score was excellent (κ = 0.82) and the correlation strong (r = 0.94). Most patients (80%) with an intermediate PTP had no or mild CAC on non–gated CT. They were reclassified at low risk with 100% accuracy compared with invasive coronary angiography. Similarly, 86% of patients had an Agatston score <300. These patients were reclassified with 98% accuracy. In patients with high PTP, the accuracy remained substantial and comparable, 94% and 89%, respectively. In conclusion, we believe this is the first study to assess the clinical applicability of CAC on non–gated CT in patients with stable chest pain, compared with the classic Agatston score. The agreement between methods was excellent and the correlation strong. Furthermore, CAC assessment on non–gated CT could reclassify patients’ risk for obstructive coronary artery disease as accurately as could the classic Agatston score. Given current pretest probability (PTP) estimations tend to overestimate patients’ risk for obstructive coronary artery disease, evaluation of patients’ coronary artery calcium (CAC) is more precise. The value of CAC assessment with the Agatston score on cardiac computed tomography (CT) for risk estimation has been well indicated in patients with stable chest pain. CAC can be equally well assessed on routine non–gated chest CT, which is often available. This study aims to determine the clinical applicability of CAC assessment on non–gated CT in patients with stable chest pain compared with the classic Agatston score on gated CT. Consecutive patients referred for evaluation of the Agatston score, who had a previously performed non–gated chest CT for evaluation of noncardiac diseases, were included. CAC on non–gated CT was ordinally scored. Subsequently, patients were stratified according to CAC severity and PTP. The agreement and correlation between the classic Agatston score and CAC on non–gated CT were evaluated. The discriminative power for risk reclassification of both CAC assessment methods was assessed. Invasive coronary angiography was used as the gold standard, when available. A total of 140 patients aged between 30 and 88 years were included. The agreement between ordinally scored CAC and the Agatston score was excellent (κ = 0.82) and the correlation strong (r = 0.94). Most patients (80%) with an intermediate PTP had no or mild CAC on non–gated CT. They were reclassified at low risk with 100% accuracy compared with invasive coronary angiography. Similarly, 86% of patients had an Agatston score <300. These patients were reclassified with 98% accuracy. In patients with high PTP, the accuracy remained substantial and comparable, 94% and 89%, respectively. In conclusion, we believe this is the first study to assess the clinical applicability of CAC on non–gated CT in patients with stable chest pain, compared with the classic Agatston score. The agreement between methods was excellent and the correlation strong. Furthermore, CAC assessment on non–gated CT could reclassify patients’ risk for obstructive coronary artery disease as accurately as could the classic Agatston score. Currently applied methods to determine patients' pretest likelihood of obstructive coronary artery disease (CAD)1Knuuti J Wijns W Saraste A Capodanno D Barbato E Funck-Brentano C Prescott E Storey RF Deaton C Cuisset T Agewall S Dickstein K Edvardsen T Escaned J Gersh BJ Svitil P Gilard M Hasdai D Hatala R Mahfoud F Masip J Muneretto C Valgimigli M Achenbach S Bax JJ ESC Scientific Document Group2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes [published correction appears in Eur Heart J 2020;41:4242].Eur Heart J. 2020; 41: 407-477Crossref PubMed Scopus (3780) Google Scholar tend to overestimate patients’ actual risk. This overestimation causes an essential overuse of noninvasive diagnostic tests. With large healthcare expenditures for diagnosing CAD2Vester MPM Eindhoven DC Bonten TN Wagenaar H Holthuis HJ Schalij MJ de Grooth GJ van Dijkman PRM. Utilization of diagnostic resources and costs in patients with suspected cardiac chest pain.Eur Heart J Qual Care Clin Outcomes. 2021; 7: 583-590Crossref PubMed Scopus (7) Google Scholar,3Timmis A Townsend N Gale CP Torbica A Lettino M Petersen SE Mossialos EA Maggioni AP Kazakiewicz D May HT De Smedt D Flather M Zuhlke L Beltrame JF Huculeci R Tavazzi L Hindricks G Bax J Casadei B Achenbach S Wright L Vardas P European Society of Cardiology. European Society of Cardiology: Cardiovascular disease statistics 2019 [published correction appears in Eur Heart J 2020;41:4507].Eur Heart J. 2020; 41: 12-85Crossref PubMed Scopus (623) Google Scholar and the current economic strain on healthcare systems, there is increasing interest in using simple, clinically available information on cardiac risk factors to optimize patient selection for additional imaging. Guidelines recommend assessing patients’ coronary artery calcium (CAC).4Gulati M Levy PD Mukherjee D Amsterdam E Bhatt DL Birtcher KK Blankstein R Boyd J Bullock-Palmer RP Conejo T Diercks DB Gentile F Greenwood JP Hess EP Hollenberg SM Jaber WA Jneid H Joglar JA Morrow DA O'Connor RE Ross MA Shaw LJ 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: A report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines.Circulation. 2021; 144: e368-e454Google Scholar Patients’ CAC is classically assessed on electrocardiogram (ECG)-gated cardiac computed tomography (CT) with the Agatston score. Coincidentally, CAC can be equally well assessed on non–gated chest CT performed for evaluation of noncardiac disease, such as pulmonary embolism.5Arad Y Spadaro LA Goodman K Newstein D Guerci AD. Prediction of coronary events with electron beam computed tomography.J Am Coll Cardiol. 2000; 36: 1253-1260Crossref PubMed Scopus (672) Google Scholar, 6Shemesh J Henschke CI Shaham D Yip R Farooqi AO Cham MD McCauley DI Chen M Smith JP Libby DM Pasmantier MW Yankelevitz DF. Ordinal scoring of coronary artery calcifications on low-dose CT scans of the chest is predictive of death from cardiovascular disease [published correction appears in Radiology. 2011 May;259(2):617].Radiology. 2010; 257: 541-548Crossref PubMed Scopus (210) Google Scholar, 7Chi JM Makaryus JN Rahmani N Shah AB Shah RD Cohen SL. Coronary CT calcium score in patients with prior nongated CT, is it necessary?.Curr Probl Diagn Radiol. 2021; 50: 54-58Crossref PubMed Scopus (4) Google Scholar, 8Hecht HS Cronin P Blaha MJ Budoff MJ Kazerooni EA Narula J Yankelevitz D Abbara S. 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: a report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology [published correction appears in J Cardiovasc Comput Tomogr 2017;11:170].J Cardiovasc Comput Tomogr. 2017; 11: 74-84Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar This simple visual method correlates well with the Agatston score on gated CT.9Htwe Y Cham MD Henschke CI Hecht H Shemesh J Liang M Tang W Jirapatnakul A Yip R Yankelevitz DF. Coronary artery calcification on low-dose computed tomography: comparison of Agatston and Ordinal Scores.Clin Full Text Full Text PDF PubMed Scopus Google Scholar, S K K HJ of methods for of coronary artery calcium on low-dose chest computed Radiol. 2021; PubMed Scopus Google Scholar, HS of visual scoring of coronary artery calcification on low-dose CT for with the Agatston Radiol. PubMed Scopus Google Scholar it can be applied as an additional tool for risk in patients with stable chest pain has to be This study aims to the clinical applicability of CAC to non–gated CT in patients with stable chest pain, compared with the Agatston score in gated CT. This study patients with stable chest pain at the of the who were referred for CAC assessment with the Agatston score. and patients were referred for evaluation of the Agatston score. patients in a non–gated chest CT was previously performed for the evaluation of noncardiac = of The patient selection is in Subsequently, we patients with coronary coronary artery or the 140 patients the study patients had a non–gated chest CT performed years of first at the Furthermore, we pretest probability (PTP) of obstructive the European Society of guidelines of J Wijns W Saraste A Capodanno D Barbato E Funck-Brentano C Prescott E Storey RF Deaton C Cuisset T Agewall S Dickstein K Edvardsen T Escaned J Gersh BJ Svitil P Gilard M Hasdai D Hatala R Mahfoud F Masip J Muneretto C Valgimigli M Achenbach S Bax JJ ESC Scientific Document Group2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes [published correction appears in Eur Heart J 2020;41:4242].Eur Heart J. 2020; 41: 407-477Crossref PubMed Scopus (3780) Google Scholar Subsequently, the patients were stratified according to PTP as of of to or of and In the patients’ were for of cardiovascular risk such as and The the for The Agatston score was performed on cardiac CT, using The A of and of were computed the Agatston score on the of the of calcification and the of the as previously Agatston M of coronary artery calcium using computed tomography.J Am Coll Cardiol. PubMed Scopus Google Scholar chest CT was performed as of routine noncardiac or as a of the patients’ for CAC The was in CAC assessment on both and scans has been P S J scoring of coronary artery calcium on and noncontrast chest a study of diagnostic and Am J PubMed Scopus Google Scholar The patients’ CAC was assessed on scans with a of methods for CAC assessment on non–gated chest S K K HJ of methods for of coronary artery calcium on low-dose chest computed Radiol. 2021; PubMed Scopus Google J scoring of coronary artery calcification in computed tomography: with and cardiovascular PubMed Scopus Google JM Y Coronary artery calcium severity on low-dose chest computed tomography: a study in a Radiol. 2020; PubMed Scopus Google Scholar The that simple visual assessment of CAC with severity on an could accurately patients’ L MA of cardiovascular risk on routine chest coronary artery calcium scoring as an of Agatston score Cardiovasc Comput Tomogr. 2017; 11: Full Text Full Text PDF PubMed Scopus Google MA C Wright of Agatston coronary calcification scoring for cardiovascular disease in J Cardiovasc PubMed Scopus Google Scholar Furthermore, this method had excellent agreement with the classic Agatston JM Makaryus JN Rahmani N Shah AB Shah RD Cohen SL. Coronary CT calcium score in patients with prior nongated CT, is it necessary?.Curr Probl Diagn Radiol. 2021; 50: 54-58Crossref PubMed Scopus (4) Google L MA of cardiovascular risk on routine chest coronary artery calcium scoring as an of Agatston score Cardiovasc Comput Tomogr. 2017; 11: Full Text Full Text PDF PubMed Scopus Google Scholar it in comparison with methods CAC severity could be in JM Y Coronary artery calcium severity on low-dose chest computed tomography: a study in a Radiol. 2020; PubMed Scopus Google Scholar this previously J Henschke CI Shaham D Yip R Farooqi AO Cham MD McCauley DI Chen M Smith JP Libby DM Pasmantier MW Yankelevitz DF. Ordinal scoring of coronary artery calcifications on low-dose CT scans of the chest is predictive of death from cardiovascular disease [published correction appears in Radiology. 2011 May;259(2):617].Radiology. 2010; 257: 541-548Crossref PubMed Scopus (210) Google L MA of cardiovascular risk on routine chest coronary artery calcium scoring as an of Agatston score Cardiovasc Comput Tomogr. 2017; 11: Full Text Full Text PDF PubMed Scopus Google de MA van Dijkman Schalij MJ Coronary calcium score in with cardiac and cardiac Heart J Google Scholar was used for CAC assessment in this In CAC is on an from to on the of CAC in coronary coronary Subsequently, the total CAC score is on the of increasing no mild to and to These were used to the of risk factors and on the agreement with the Agatston score no mild to and HS Cronin P Blaha MJ Budoff MJ Kazerooni EA Narula J Yankelevitz D Abbara S. 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: a report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology [published correction appears in J Cardiovasc Comput Tomogr 2017;11:170].J Cardiovasc Comput Tomogr. 2017; 11: 74-84Abstract Full Text Full Text PDF PubMed Scopus (259) Google S K K HJ of methods for of coronary artery calcium on low-dose chest computed Radiol. 2021; PubMed Scopus Google HS Blaha MJ Kazerooni EA Budoff M J Shaw coronary artery calcium and of the Society of Cardiovascular Computed Tomography Cardiovasc Comput Tomogr. 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A study L G A value of coronary artery calcification on computed tomography for of and Cardiovasc Comput Tomogr. 2017; 11: Full Text Full Text PDF PubMed Scopus Google Scholar compared the predictive value of no CAC with that of an Agatston score of in patients who were referred a They a for both visual CAC on non–gated CT and an Agatston score of and respectively. both methods could patients’ risk for cardiovascular J C H L H C Y Y Y H Y J Chen Y of to cardiac in patients with stable chest Cardiovasc PubMed Scopus Google D van D van Dijkman PRM. of guidelines for diagnosing suspected stable and the additional value of the calcium J Cardiol. 2021; Full Text Full Text PDF PubMed Scopus Google Scholar compared risk with risk estimation methods for of chest pain They which method of risk estimation could patients at low risk for obstructive risk estimation the and predictive value the risk the of no previously CAC on non–gated CT for risk A of CAC assessment in risk for obstructive is the costs of performed additional noninvasive diagnostic no or mild CAC can accurately patients for noninvasive additional and a high CAC score could of A study DA F P C S J C J de P H M Coronary artery calcium score as a for in patients with low pretest probability of obstructive coronary artery a Cardiol. 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Furthermore, the discriminative power of CAC on non–gated CT for risk reclassification of patients with was and compared with the discriminative power of the Agatston score on gated CT. CAC assessment on non–gated CT could accurately patients who were at low risk for obstructive and had equal discriminative power to that of the Agatston score on CT. when CAC on non–gated chest CT can be used as an additional tool for clinical evaluation of patients with stable chest pain. recommend to is available and the available no non–gated CT has been the Agatston score on cardiac CT the of cost-free CAC assessment on non–gated CT as a for in patients with stable chest pain could The no to with

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