Combined use of exercise electrocardiography, coronary calcium score and cardiac CT angiography for the prediction of major cardiovascular events in patients presenting with stable chest pain.
BACKGROUND
The usual diagnostic work-up of chest pain patients includes clinical risk profiling and exercise-ECG, possibly followed by additional tests. Recently cardiac computed tomographic angiography (CCTA) has been employed. We evaluated the prognostic value of the combined use of exercise-ECG and CCTA for the development of cardiovascular endpoints.


METHODS
In 283 patients (143 male, mean age 54 ± 10 years) with intermediate pre-test probability for coronary artery disease presenting with stable chest pain, exercise-ECG, CCTA and calcium score were performed. Patients were followed-up for combined endpoint of acute coronary syndrome (ACS) and revascularization.


RESULTS
After a median follow-up of 769 days (interquartile range 644-1007), 6 ACS and 9 revascularizations were recorded. A positive exercise-ECG predicted for the combined endpoint, [hazard ratio (HR) 5.14 (95% confidence interval (CI) 1.64-16.13), p=0.005], as well as a positive calcium score [HR 4.59 (95% CI 1.30-16.28), p=0.02] and a ≥ 50% stenosis on CCTA [HR 45.82 (95% CI 6.02-348.54), p<0.001]. ROC-analysis showed an area under the curve (AUC) of 0.79 (95% CI 0.67-0.90) for exercise-ECG, which increased significantly when CCTA was added: 0.91 (95% CI; 0.86-0.97; p=0.006). Multivariable Cox regression showed exercise-ECG predicted independently [HR 3.6, (95% CI 1.1-11.2), p=0.03], as well as CCTA [HR 31.4 (95% CI 4.0-246.6), p=0.001], but not calcium score [HR 0.6 (95% CI 0.2-2.3), p=0.5].


CONCLUSIONS
The combined subsequent use of exercise-ECG for functional information and CCTA for anatomical information provides a high diagnostic yield in stable chest pain patients with an intermediate pre-test probability for coronary artery disease.
Department of Cardiology, Maastricht University Medic\al Center, Maastricht, The Netherlands. mathijs.versteylen@mumc.nl
Mathijs O
MO
Versteylen
Ivo A
IA
Joosen
Mark H
MH
Winkens
Eduard M
EM
Laufer
Roel J
RJ
Snijder
Joachim E
JE
Wildberger
Harry J
HJ
Crijns
Jagat
J
Narula
Leonard
L
Hofstra
D000368:Aged; D002637:Chest Pain / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000503:physiopathology; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000503:physiopathology; D004562:Electrocardiography / Q000379:methods*; D005080:Exercise Test / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006801:Humans; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography / Q000379:methods*; D012189:Retrospective Studies; D012307:Risk Factors