title: The coronary calcium treadmill test: a new approach to the initial workup of patients with suspected coronary artery disease.
abstract: Due to the growth of cardiac testing and increasing cost of cardiovascular healthcare, the development of more cost-effective strategies has now become a dominant issue regarding future utilization of cardiac imaging procedures. To that end, we review the potential of combining two relatively inexpensive tests, the coronary artery calcium (CAC) scan and exercise electrocardiography (ECG), as a first-line test for the workup of patients with suspected coronary artery disease (CAD). The CAC scan was initially introduced as a screening test for CAD, based on data indicating that it is a specific marker for atherosclerosis, predicts clinical risk in accordance with the magnitude of CAC, and provides incremental information for prognostic risk compared to more readily available clinical data. However, CAC scores also predict the likelihood of observing myocardial ischemia among patients undergoing exercise myocardial perfusion SPECT imaging. Exercise ECG predicts clinical events according to the ST-segment response and according to functional exercise capacity, with the latter parameter as a stronger predictor of clinical outcomes. Like CAC scores, exercise functional capacity can also be used to predict the likelihood of ischemia since ischemia diminishes proportionally with increasing exercise capacity. Recent work indicates that when patients are designated by Bayesian analyses into low, intermediate, and high likelihood categories for CAD based on clinical data and the response to exercise ECG, the frequency of inducible myocardial ischemia is very low among both low and intermediate CAD likelihood patients who have a CAC score <400. Future studies are needed to investigate what clinical factors might further modify the CAC-ischemia relationship. On the basis of current data, an initial testing strategy that employs the combined calcium treadmill test has the inherent ability to designate a substantial number of intermediate likelihood patients who would not require further testing due to relatively low CAC scores and reasonable functional capacity.
authors: Division of Cardiology and Department of Medicine, St. Lukes Roosevelt Hospital, 1111 Amsterdam Avenue, New York, NY, 10025, USA, ar77@columbia.edu.
authors: Alan
authors: A
authors: Rozanski
authors: Randy
authors: R
authors: Cohen
authors: Seth
authors: S
authors: Uretsky
mesh_terms: D050197:Atherosclerosis / Q000175:diagnosis; D002118:Calcium / Q000378:metabolism*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging*; D003362:Cost-Benefit Analysis; D004562:Electrocardiography; D005080:Exercise Test / Q000379:methods*; D005471:Fluoroscopy; D006801:Humans; D008279:Magnetic Resonance Imaging; D017202:Myocardial Ischemia / Q000473:pathology; D055414:Myocardial Perfusion Imaging; D011379:Prognosis; D012372:ROC Curve; D012306:Risk; D013997:Time Factors; D015899:Tomography, Emission-Computed, Single-Photon; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D002118:Calcium
references: Eur Heart J. 2002 Oct;23(20):1596-1603
references: 12323159
references: N Engl J Med. 2008 Mar 27;358(13):1336-45
references: 18367736
references: Am J Cardiol. 2000 Sep 1;86(5):495-8
references: 11009264
references: Am Heart J. 2009 Oct;158(4):554-61
references: 19781414
references: J Am Coll Cardiol. 2007 May 8;49(18):1860-70
references: 17481445
references: Circulation. 2004 Aug 3;110(5):522-7
references: 15262842
references: J Am Coll Cardiol. 1998 Jan;31(1):126-33
references: 9426030
references: Circulation. 2001 Jul 24;104(4):412-7
references: 11468202
references: Radiology. 2003 Sep;228(3):826-33
references: 12869688
references: J Am Coll Cardiol. 2000 Oct;36(4):1253-60
references: 11028480
references: Circulation. 2003 May 27;107(20):2571-6
references: 12743005