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. 2023 Aug;16(8):e015236.
doi: 10.1161/CIRCIMAGING.123.015236. Epub 2023 Aug 10.

Interplay Between Zero CAC, Quantitative Plaque Analysis, and Adverse Events in a Diverse Patient Cohort

Michael Fattouh #  1 , Toshiki Kuno #  1 , Pamela Pina  1 , John P Skendelas  2 , Daniel Lorenzatti  1 , Javier Arce  1 , Jonathan Daich  1 , Gustavo Duarte  1 , Carol Fernandez-Hazim  1 , Miguel Rodriguez-Guerra  1 , Patrick Neshiwat  1 , Aldo L Schenone  1 , Lili Zhang  1 , Carlos J Rodriguez  1 , Armin Arbab-Zadeh  3 , Piotr J Slomka  4 , Salim S Virani  5   6 , Michael J Blaha  3 , Daniel S Berman  4 , Damini Dey  4 , Mario J Garcia  1 , Leandro Slipczuk  1
Affiliations

Interplay Between Zero CAC, Quantitative Plaque Analysis, and Adverse Events in a Diverse Patient Cohort

Michael Fattouh et al. Circ Cardiovasc Imaging. 2023 Aug.

Abstract

Background: Coronary artery calcium scoring (CAC) has garnered attention in the diagnostic approach to chest pain patients. However, little is known about the interplay between zero CAC, sex, race, ethnicity, and quantitative coronary plaque analysis.

Methods: We conducted a retrospective analysis from our computed tomography registry of patients with stable angina without prior myocardial infarction or revascularization undergoing coronary computed tomography angiography at Montefiore Healthcare System. Follow-up end points collected included invasive angiography, type-1 myocardial infarction, coronary revascularization, cardiovascular and all-cause death.

Results: A total of 2249 patients were included (66% female). The median follow-up was 5.5 years. The median age of those without CAC was 52 years (interquartile range, 44-59) and 60 years (interquartile range, 53-68) in those with CAC. Most patients were Hispanic (58%), and the rest were non-Hispanic Black (28%), non-Hispanic White (10%), and non-Hispanic Asian (5%). The majority had CAC=0 (55%). The negative predictive value of CAC=0 was 92.8%, 99.9%, and 99.9% for any plaque, obstructive coronary artery stenosis, and the composite outcome of all-cause death, myocardial infarction, or coronary revascularization, respectively. Among patients without CAC (n=1237), 89 patients (7%) had evidence of plaque on their coronary computed tomography angiography with a median low-attenuation noncalcified plaque burden of 4% (2-7). There were no significant differences in the negative predictive value for CAC=0 by sex, race, or ethnicity. Patients with ≥2 risk factors had higher odds of having plaque with zero CAC.

Conclusions: In summary, no sex, race, or ethnicity differences were demonstrated in the negative predictive value of a zero CAC; however, patients with ≥2 risk factors had a higher prevalence of plaque. A small percentage (7%) of symptomatic patients undergoing coronary computed tomography angiography with zero CAC had noncalcified coronary plaque, with the implication that caution is needed for downscaling of preventive treatment in patients with zero CAC, chest pain, and multiple risk factors.

Keywords: cardiovascular; chest pain; coronary artery calcium score; plaque analysis; power of zero.

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Conflict of interest statement

Disclosures Dr Virani has received research support from the Department of Veterans Affairs, National Institutes of Health (NIH), Tahir and Jooma Family and Honorarium from American College of Cardiology (Associate Editor for Innovations, acc.org). Dr Slipczuk has received consulting honorarium from Amgen, Regeneron, and Philips; and Grant support from Amgen. Drs Slomka, Berman, and Dey have received software royalties from Cedars-Sinai Medical Center. Dr Dey was supported by grants from National Heart, Lung and Blood Institute (1R01HL148787–01A1 and R01HL151266 and NIH diversity administrative supplement for grant R01 HL148787). Dr Blaha has received grants from NIH, Novo Nordisk, Novartis. Dr Zhang has received a grant from the New York Academy of Medicine. Dr Rodriguez is supported by grant from the NIH (R01 HL04199, 75N92019D00011, 1U01HL146204-01, 5R01HL144707) and the American Heart Association (5P50HL120163-04) and has participated in Advisory Boards for Amgen and has worked as a Consultant for Merck. Other authors declare no conflict.

Figures

Figure 1.
Figure 1.. Stenosis distribution among CAC groups.
Bars show the coronary stenosis distribution amongst patients with zero CAC (CAC=0) versus CAC >0. CAC: coronary artery calcium scoring, CAD-RADS: Coronary Artery Disease Reporting and Data System
Figure 2.
Figure 2.. Clinical outcomes among CAC groups.
(A) Bars show the numbers of patients with clinical outcomes in patients with zero CAC (CAC=0) and CAC>0. (B) Unadjusted cumulative risk for the composite outcome of death, myocardial infarction and subsequent revascularization. (C) Unadjusted cumulative risk for the composite outcome of cardiovascular death, myocardial infarction and subsequent revascularization. CABG: coronary artery bypass surgery, CAC: coronary artery calcium, CAD: coronary artery disease, LHC: left heart catheterization, MI: myocardial infarction, PCI: percutaneous coronary intervention.
Figure 2.
Figure 2.. Clinical outcomes among CAC groups.
(A) Bars show the numbers of patients with clinical outcomes in patients with zero CAC (CAC=0) and CAC>0. (B) Unadjusted cumulative risk for the composite outcome of death, myocardial infarction and subsequent revascularization. (C) Unadjusted cumulative risk for the composite outcome of cardiovascular death, myocardial infarction and subsequent revascularization. CABG: coronary artery bypass surgery, CAC: coronary artery calcium, CAD: coronary artery disease, LHC: left heart catheterization, MI: myocardial infarction, PCI: percutaneous coronary intervention.
Figure 2.
Figure 2.. Clinical outcomes among CAC groups.
(A) Bars show the numbers of patients with clinical outcomes in patients with zero CAC (CAC=0) and CAC>0. (B) Unadjusted cumulative risk for the composite outcome of death, myocardial infarction and subsequent revascularization. (C) Unadjusted cumulative risk for the composite outcome of cardiovascular death, myocardial infarction and subsequent revascularization. CABG: coronary artery bypass surgery, CAC: coronary artery calcium, CAD: coronary artery disease, LHC: left heart catheterization, MI: myocardial infarction, PCI: percutaneous coronary intervention.
See this image and copyright information in PMC

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