title: Restriction of the referral of patients with stable angina for CT coronary angiography by clinical evaluation and calcium score: impact on clinical decision making.
abstract: OBJECTIVE
  To investigate the value of the calcium score (CaSc) plus clinical evaluation to restrict referral for CT coronary angiography (CTCA) by reducing the number of patients with an intermediate probability of coronary artery disease (CAD).
  
  
  METHODS
  We retrospectively included 1,975 symptomatic stable patients who underwent clinical evaluation and CaSc calculation and CTCA or invasive coronary coronary angiography (ICA). The outcome was obstructive CAD (≥50 % diameter narrowing) assessed by ICA or CTCA in the absence of ICA. We investigated two models: (1) clinical evaluation consisting of chest pain typicality, gender, age, risk factors and ECG and (2) clinical evaluation with CaSc. Discrimination of the two models was compared. The stepwise reclassification of patients with an intermediate probability of CAD (10-90 %) after clinical evaluation followed by clinical evaluation with CaSc was assessed by clinical net reclassification improvement (NRI).
  
  
  RESULTS
  Discrimination of CAD was significantly improved by adding CaSc to the clinical evaluation (AUC: 0.80 vs. 0.89, P < 0.001). CaSc and CTCA could be avoided in 9 % using model 1 and an additional 29 % of CTCAs could be avoided using model 2. Clinical NRI was 57 %.
  
  
  CONCLUSIONS
  CaSc plus clinical evaluation may be useful in restricting further referral for CTCA by 38 % in symptomatic stable patients with suspected CAD.
  
  
  CONCLUSIONS
  • CT calcium scores (CaSc) could proiritise referrals for CT coronary angiography (CTCA) • CaSc provides an incremental discriminatory value of CAD compared with clinical evaluation • Risk stratification is better when clinical evaluation is combined with CaSc • Appropriate use of clinical evaluation and CaSc helps avoid unnecessary CTCA referrals.
authors.affiliation: Erasmus MC Department of Radiology, room Ca 207a, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands, a.dharampal@erasmusmc.nl.
authors.forename: Anoeshka S
authors.initials: AS
authors.lastname: Dharampal
authors.forename: Alexia
authors.initials: A
authors.lastname: Rossi
authors.forename: Admir
authors.initials: A
authors.lastname: Dedic
authors.forename: Filippo
authors.initials: F
authors.lastname: Cademartiri
authors.forename: Stella L
authors.initials: SL
authors.lastname: Papadopoulou
authors.forename: Annick C
authors.initials: AC
authors.lastname: Weustink
authors.forename: Bart S
authors.initials: BS
authors.lastname: Ferket
authors.forename: Eric
authors.initials: E
authors.lastname: Boersma
authors.forename: Willem B
authors.initials: WB
authors.lastname: Meijboom
authors.forename: Tjebbe W
authors.initials: TW
authors.lastname: Galema
authors.forename: Koen
authors.initials: K
authors.lastname: Nieman
authors.forename: Pim J
authors.initials: PJ
authors.lastname: de Feyter
authors.forename: Gabriel P
authors.initials: GP
authors.lastname: Krestin
mesh_terms: D002114:Calcinosis / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D015897:Comorbidity; D017023:Coronary Angiography / Q000706:statistics & numerical data*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D005260:Female; D015276:Health Care Rationing / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D018579:Patient Selection; D015995:Prevalence; D011379:Prognosis; D016016:Proportional Hazards Models; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*