Researchers Highlight Coronary Artery Calcium Scoring as New Gatekeeper for Evaluating Stable Chest Pain
USA: A recent editorial comment in the Journal of the American College of Cardiology: Cardiovascular Imaging highlights the evolving role of coronary artery calcium (CAC) scoring as a critical tool for evaluating patients with stable chest pain. Traditionally, clinicians relied on the Diamond-Forrester model, which estimates the likelihood of obstructive coronary artery disease (CAD) based on age, sex, and angina characteristics. However, contemporary analyses suggest that this model may overestimate CAD probabilities and fail to incorporate newer testing methods.
The editorial references current guidelines, including the 2021 American Heart Association/American College of Cardiology Multisociety Chest Pain Guidelines, which advocate for integrating cardiovascular risk factors and CAC scores to refine the pretest probability (PTP) of CAD in patients with chest pain. According to the editorial authors David E. Winchester, and Mahmoud Al Rifai (both from USA), this is particularly relevant given that stable chest pain can indicate varying levels of underlying cardiovascular issues.
In the featured study by Rasmussen et al., which included 4,371 patients undergoing anatomical assessment for CAD, the researchers assessed the effectiveness of different PTP models. The findings indicated that both risk factor-weighted clinical likelihood (RF-CL) and CAC score-weighted clinical likelihood (CACS-CL) models provided significantly improved predictions for hemodynamically obstructive CAD compared to the basic PTP model. Notably, CAC scoring demonstrated a 98.9% negative predictive value for obstructive CAD, making it an effective tool for ruling out serious conditions.
The editorial emphasizes that while CAC scoring alone can serve as a valuable screening tool, it is crucial to consider individual clinical characteristics to minimize misclassification of CAD status. With nearly half of patients presenting with stable chest pain potentially having a CAC score of zero, the absence of coronary artery calcium suggests that further testing may be unnecessary.
Future recommendations from the 2023 Appropriate Use Criteria for multimodality imaging in chronic coronary disease reinforce this perspective. These guidelines suggest that for patients with low to intermediate PTP for CAD, a negative CAC score could warrant deferring further testing. Conversely, the presence of CAC might indicate the need for additional assessments, such as coronary computed tomography angiography or myocardial perfusion imaging.
Despite its promise, challenges remain in determining which patients would benefit most from CAC scoring. The editorial underscores the need for ongoing research to evaluate various PTP strategies and refine how CAC can be used effectively in clinical practice. Ultimately, the integration of CAC scoring into routine assessments could lead to more accurate and safer management of patients with stable chest pain, improving overall cardiovascular care.
Reference:
Winchester DE, Al Rifai M. Coronary Artery Calcium as a Gatekeeper for Patients With Stable Chest Pain. JACC Cardiovasc Imaging. 2024 Oct;17(10):1211-1213. doi: 10.1016/j.jcmg.2024.05.025. Epub 2024 Aug 7. PMID: 39115500.
