title: High coronary artery calcium score affects clinical outcome despite normal stress myocardial perfusion imaging and normal left ventricular ejection fraction.
abstract: BACKGROUND
  Normal myocardial perfusion imaging (MPI) indicates a low risk for cardiac death and new ischaemic events. However, the impact of normal MPI combined with a high coronary artery calcium score (CACS) is not clear. The aims of this study were to evaluate the risk of severely elevated CACS and to identify other risk factors in patients with normal MPI.
  
  
  METHODS
  The study included 318 consecutive patients who underwent a Tc-sestamibi MPI protocol along with either the ergometer bicycle test or the pharmacological stress test. Acquisition of CACS was performed immediately before MPI. Patient history and events were retrieved from hospital files. The median follow-up time was 989 days. End points were myocardial infarction, need for revascularization of coronary arteries and/or death.
  
  
  RESULTS
  CACS was less than 400 in 256 patients (81%) and at least 400 in 62 patients with normal MPI. Cox regression analysis showed that CACS was a predictor of cardiovascular events or death [relative risk (RR) 3.4, P=0.008]. Inability to perform the ergometer stress test (RR 5.6, P=0.02) was also included in the model. CACS (RR 4.2, P=0.01) and diabetes (RR 3.7, P=0.03) were the strongest predictors of cardiac events without death.
  
  
  CONCLUSIONS
  CACS is the single most important predictor of cardiac events and/or death in patients with normal MPI. If possible, CACS could be included when performing MPI to identify patients with an increased risk for cardiac events and/or death.
authors.affiliation: Department of Clinical Physiology and Nuclear Medicine, Herlev Hospital, University Hospital of Copenhagen, Herlev, Denmark. cljuma01@heh.regionh.dk
authors.forename: Claus
authors.initials: C
authors.lastname: Madsen
authors.forename: Kim F
authors.initials: KF
authors.lastname: Andersen
authors.forename: Bo
authors.initials: B
authors.lastname: Zerahn
mesh_terms: D000241:Adenosine; D000368:Aged; D003326:Coronary Circulation; D003331:Coronary Vessels / Q000000981:diagnostic imaging*; D003920:Diabetes Mellitus; D004176:Dipyridamole; D005080:Exercise Test; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging; D009203:Myocardial Infarction / Q000453:epidemiology*; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D009204:Myocardial Revascularization / Q000706:statistics & numerical data*; D049268:Positron-Emission Tomography; D012044:Regression Analysis; D013318:Stroke Volume; D014057:Tomography, X-Ray Computed; D061205:Vascular Calcification / Q000000981:diagnostic imaging*; D014665:Vasodilator Agents
chemical_list: D014665:Vasodilator Agents; D004176:Dipyridamole; D000241:Adenosine