title: The absence of coronary calcification does not exclude obstructive coronary artery disease or the need for revascularization in patients referred for conventional coronary angiography.
abstract: OBJECTIVE
  This study was designed to evaluate whether the absence of coronary calcium could rule out >or=50% coronary stenosis or the need for revascularization.
  
  
  BACKGROUND
  The latest American Heart Association guidelines suggest that a calcium score (CS) of zero might exclude the need for coronary angiography among symptomatic patients.
  
  
  METHODS
  A substudy was made of the CORE64 (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors) multicenter trial comparing the diagnostic performance of 64-detector computed tomography to conventional angiography. Patients clinically referred for conventional angiography were asked to undergo a CS scan up to 30 days before.
  
  
  RESULTS
  In all, 291 patients were included, of whom 214 (73%) were male, and the mean age was 59.3 +/- 10.0 years. A total of 14 (5%) patients had low, 218 (75%) had intermediate, and 59 (20%) had high pre-test probability of obstructive coronary artery disease. The overall prevalence of >or=50% stenosis was 56%. A total of 72 patients had CS = 0, among whom 14 (19%) had at least 1 >or=50% stenosis. The overall sensitivity for CS = 0 to predict the absence of >or=50% stenosis was 45%, specificity was 91%, negative predictive value was 68%, and positive predictive value was 81%. Additionally, revascularization was performed in 9 (12.5%) CS = 0 patients within 30 days of the CS. From a total of 383 vessels without any coronary calcification, 47 (12%) presented with >or=50% stenosis; and from a total of 64 totally occluded vessels, 13 (20%) had no calcium.
  
  
  CONCLUSIONS
  The absence of coronary calcification does not exclude obstructive stenosis or the need for revascularization among patients with high enough suspicion of coronary artery disease to be referred for coronary angiography, in contrast with the published recommendations. Total coronary occlusion frequently occurs in the absence of any detectable calcification. (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors [CORE-64]; NCT00738218).
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: Ilan
authors.initials: I
authors.lastname: Gottlieb
authors.forename: Julie M
authors.initials: JM
authors.lastname: Miller
authors.forename: Armin
authors.initials: A
authors.lastname: Arbab-Zadeh
authors.forename: Marc
authors.initials: M
authors.lastname: Dewey
authors.forename: Melvin E
authors.initials: ME
authors.lastname: Clouse
authors.forename: Leonardo
authors.initials: L
authors.lastname: Sara
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Niinuma
authors.forename: David E
authors.initials: DE
authors.lastname: Bush
authors.forename: Narinder
authors.initials: N
authors.lastname: Paul
authors.forename: Andrea L
authors.initials: AL
authors.lastname: Vavere
authors.forename: John
authors.initials: J
authors.lastname: Texter
authors.forename: Jeffery
authors.initials: J
authors.lastname: Brinker
authors.forename: João A C
authors.initials: JA
authors.lastname: Lima
authors.forename: Carlos E
authors.initials: CE
authors.lastname: Rochitte
mesh_terms: D000367:Age Factors; D002114:Calcinosis / Q000000981:diagnostic imaging*; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging*; D054059:Coronary Occlusion / Q000000981:diagnostic imaging* / Q000628:therapy; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000628:therapy; D005260:Female; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012017:Referral and Consultation; D012680:Sensitivity and Specificity; D012737:Sex Factors; D014057:Tomography, X-Ray Computed / Q000379:methods