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Meta-Analysis
. 2022 Oct;15(10):1745-1757.
doi: 10.1016/j.jcmg.2022.03.031. Epub 2022 Jun 15.

The Prognostic Value of CAC Zero Among Individuals Presenting With Chest Pain: A Meta-Analysis

Ali M Agha  1 , Justin Pacor  2 , Gowtham R Grandhi  3 , Reed Mszar  2 , Safi U Khan  4 , Roosha Parikh  4 , Tanushree Agrawal  4 , Jeremy Burt  5 , Ron Blankstein  6 , Michael J Blaha  7 , Leslee J Shaw  8 , Mouaz H Al-Mallah  4 , Alexandria Brackett  9 , Miguel Cainzos-Achirica  4 , Edward J Miller  10 , Khurram Nasir  11
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Free article
Meta-Analysis

The Prognostic Value of CAC Zero Among Individuals Presenting With Chest Pain: A Meta-Analysis

Ali M Agha et al. JACC Cardiovasc Imaging. 2022 Oct.
Free article

Abstract

Background: There is little consensus on whether absence of coronary artery calcium (CAC) can identify patients with chest pain (CP) who can safely avoid additional downstream testing.

Objectives: The purpose of this study was to conduct a systematic review and meta-analysis investigating the utility of CAC assessment for ruling out obstructive coronary artery disease (CAD) among patients with stable and acute CP, at low-to-intermediate risk of obstructive CAD undergoing coronary computed tomography angiography (CTA).

Methods: The authors searched online databases for studies published between 2005 and 2021 examining the relationship between CAC and obstructive CAD (≥50% coronary luminal narrowing) on coronary CTA among patients with stable and acute CP.

Results: In this review, the authors included 19 papers comprising 79,903 patients with stable CP and 13 papers including 12,376 patients with acute CP undergoing simultaneous CAC and coronary CTA assessment. Overall, 45% (95% CI: 40%-50%) of patients with stable CP and 58% (95% CI: 50%-66%) of patients with acute CP had CAC = 0. The negative predictive values for CAC = 0 ruling out obstructive CAD were 97% (95% CI: 96%-98%) and 98% (95% CI: 96%-99%) among patients with stable and acute CP, respectively. Additionally, the prevalence of nonobstructive CAD among those with CAC = 0 was 13% (95% CI: 10%-16%) among those with stable CP and 9% (95% CI: 5%-13%) among those with acute CP. A CAC score of zero predicted a low incidence of major adverse cardiac events among patients with stable CP (0.5% annual event rate) and acute CP (0.8% overall event rate).

Conclusions: Among over 92,000 patients with stable or acute CP, the absence of CAC was associated with a very low prevalence of obstructive CAD, a low prevalence of nonobstructive CAD, and a low annualized risk of major adverse cardiac events. These findings support the role of CAC = 0 in a value-based health care delivery model as a "gatekeeper" for more advanced imaging among patients presenting with CP.

Keywords: atherosclerosis; chest pain; coronary artery calcium; coronary computed tomography angiography.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Nasir is on the advisory board of Amgen, Novartis, and The Medicines Company; and his research is partly supported by the Jerold B. Katz Academy of Translational Research. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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