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. 2023 Aug;30(4):1514-1527.
doi: 10.1007/s12350-022-03174-3. Epub 2023 Jan 9.

The power of zero calcium in 82-Rubidium PET irrespective of sex and age

Simon M Frey  1   2 , Olivier F Clerc  3   4 , Ursina Honegger  4 , Melissa Amrein  4 , Kathrin Thommen  3 , Federico Caobelli  5 , Philip Haaf  3   4 , Christian E Müller  3   4 , Michael J Zellweger  3   4
Affiliations

The power of zero calcium in 82-Rubidium PET irrespective of sex and age

Simon M Frey et al. J Nucl Cardiol. 2023 Aug.

Abstract

Background: Despite clinical suspicion, many non-invasive tests for coronary artery disease (CAD) are normal. Coronary artery calcification score (CACS) is a well-validated method to detect and risk stratify CAD. Patients with zero calcium score (ZCS) rarely have abnormal tests. Therefore, aims were to evaluate CACS as a gatekeeper to further functional downstream testing for CAD and estimate potential radiation and cost savings.

Methods: Consecutive patients with suspected CAD referred for PET were included (n = 2640). Prevalence and test characteristics of ZCS were calculated in different groups. Summed stress score ≥ 4 was considered abnormal and summed difference score ≥ 7 equivalent to ≥ 10% ischemia. To estimate potential radiation/cost reduction, PET scans were hypothetically omitted in ZCS patients.

Results: Mean age was 65 ± 11 years, 46% were female. 21% scans were abnormal and 26% of patients had ZCS. CACS was higher in abnormal PET (median 561 vs 27, P < 0.001). Abnormal PET was significantly less frequent in ZCS patients (2.6% vs 27.6%, P < 0.001). Sensitivity/negative predictive value (NPV) of ZCS to detect/exclude abnormal PET and ≥ 10% ischemia were 96.8% (95%-CI 95.0%-97.9%)/97.4% (95.9%-98.3%) and 98.9% (96.7%-99.6%)/99.6% (98.7%-99.9%), respectively. Radiation and cost reduction were estimated to be 23% and 22%, respectively.

Conclusions: ZCS is frequent, and most often consistent with normal PET scans. ZCS offers an excellent NPV to exclude an abnormal PET and ≥ 10% ischemia across different gender and age groups. CACS is a suitable gatekeeper before advanced cardiac imaging, and potential radiation/cost savings are substantial. However, further studies including safety endpoints are needed.

Keywords: 82Rubdium positron emission tomography; calcium artery calcium score; coronary artery disease; ischemia; power of zero; risk assessment.

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Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Figure 1
Figure 1
Diagnostic yield of CACS for abnormal scan (SSS ≥ 4). The upper value indicates the 90th percentile of CACS in patients with normal PET (SSS < 4). The lower value indicates the 5th percentile of CACS in patients with abnormal PET (SSS ≥ 4). The prevalence of abnormal PET and number of patients within each area are indicated. For better readability, different scales for absolute CACS were used
Figure 2
Figure 2
Diagnostic yield of CACS for ≥ 10% ischemia (SDS ≥ 7). The upper value indicates the 90th percentile of CACS in patients with no ischemia involving ≥ 10% of myocardium (SDS < 7). The lower value indicates the 5th percentile of CACS in patients with ≥ 10% ischemia (SDS ≥ 7). The prevalence of ≥ 10% ischemia and number of patients within each area are indicated. For better readability, different scales for absolute CACS were used
Figure 3
Figure 3
The power of zero calcium score. Zero calcium score (ZCS) is frequent and declines with higher age (A). Calcium score has a good diagnostic performance (ROC analysis for predicting abnormal PET (SSS ≥ 4) and ≥ 10% ischemia (SDS ≥ 7)) (B). Test characteristics of ZCS are excellent to exclude abnormal PET or ≥ 10% ischemia irrespective of age and gender (C). Abnormal PET is infrequent in patients with ZCS (panel D). The illustrating images show a positive Calcium Score in the left main and left anterior descending artery with corresponding anterior/anteroseptal ischemia
See this image and copyright information in PMC

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