Advertisement

Usefulness of Coronary Artery Calcium Score to Rule Out Obstructive Coronary Artery Disease Before Transcatheter Aortic Valve Implantation

Published:September 14, 2022DOI:https://doi.org/10.1016/j.amjcard.2022.07.030
      Pretranscatheter aortic valve implantation (pre-TAVI) coronary evaluation using computed tomography coronary angiography (CTA) remains suboptimal. We aimed to evaluate whether coronary artery calcium score (CAC) may rule out obstructive coronary artery disease (CAD) pre-TAVI. TAVI candidates (n = 230; mean age 80 ± 8 years), 49% men, underwent preprocedural CTA and invasive coronary angiography. Obstructive CAD was defined as luminal diameter stenosis of ≥50% of left main or 3 major vessels ≥70%. Vessels with coronary stents or bypass were excluded. CAC score was calculated using the Agatston method. Receiver operating characteristic was applied to establish the CAC threshold for obstructive CAD. Multivariable analysis with adjustment for clinical covariates was applied. Net reclassification for nonobstructive disease using CAC score was calculated among nondiagnostic CT scans. Median CAC score was 1,176 (interquartile range 613 to 1,967). Receiver operating characteristic analysis showed high negative predictive value (NPV) for obstructive CAD as follows: left main CAC score 252, NPV 99%; left anterior descending CAC score 250, NPV 97%; left circumflex CAC score 297, NPV 92%; and right coronary artery CAC score 250, NPV 91%. Multivariate analysis showed the highest tertile of CAC score (≥1,670) to be an independent predictor of obstructive CAD (odds ratio 10.7, 95% confidence interval 4.6 to 25, p <0.001). Among nondiagnostic CTA, net reclassification showed reclassification of 76%, 13%, 45%, and 34% of left main, left anterior descending, left circumflex, and right coronary artery for nonobstructive CAD, respectively. In conclusion, CAC score cutoffs can be used to predict nonobstructive CAD. Implementing CAC score on pre-TAVI imaging can reduce a significant proportion of invasive coronary angiography.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Lefèvre T
        • Kappetein AP
        • Wolner E
        • Nataf P
        • Thomas M
        • Schächinger V
        • De Bruyne B
        • Eltchaninoff H
        • Thielmann M
        • Himbert D
        • Romano M
        • Serruys P
        • Wimmer-Greinecker G
        • Investigator Group PARTNER EU
        One year follow-up of the multi-centre European PARTNER transcatheter heart valve study.
        Eur Heart J. 2011; 32: 148-157
        • Zahn R
        • Gerckens U
        • Grube E
        • Linke A
        • Sievert H
        • Eggebrecht H
        • Hambrecht R
        • Sack S
        • Hauptmann KE
        • Richardt G
        • Figulla HR
        • Senges J
        • Transcatheter German
        Aortic Valve Interventions-Registry Investigators. Transcatheter aortic valve implantation: first results from a multi-centre real-world registry.
        Eur Heart J. 2011; 32: 198-204
        • Walther T
        • Hamm CW
        • Schuler G
        • Berkowitsch A
        • Kötting J
        • Mangner N
        • Mudra H
        • Beckmann A
        • Cremer J
        • Welz A
        • Lange R
        • Kuck KH
        • Mohr FW
        • Möllmann H
        • Executive Board GARY
        Perioperative results and complications in 15,964 transcatheter aortic valve replacements: prospective data From the GARY registry.
        J Am Coll Cardiol. 2015; 65: 2173-2180
        • Andreini D
        • Pontone G
        • Mushtaq S
        • Bartorelli AL
        • Ballerini G
        • Bertella E
        • Segurini C
        • Conte E
        • Annoni A
        • Baggiano A
        • Formenti A
        • Fusini L
        • Tamborini G
        • Alamanni F
        • Fiorentini C
        • Pepi M.
        Diagnostic accuracy of multidetector computed tomography coronary angiography in 325 consecutive patients referred for transcatheter aortic valve replacement.
        Am Heart J. 2014; 168: 332-339
        • Hamdan A
        • Wellnhofer E
        • Konen E
        • Kelle S
        • Goitein O
        • Andrada B
        • Raanani E
        • Segev A
        • Barbash I
        • Klempfner R
        • Goldenberg I
        • Guetta V
        Coronary CT angiography for the detection of coronary artery stenosis in patients referred for transcatheter aortic valve replacement.
        J Cardiovasc Comput Tomogr. 2015; 9: 31-41
        • Pontone G
        • Andreini D
        • Bartorelli AL
        • Annoni A
        • Mushtaq S
        • Bertella E
        • Formenti A
        • Cortinovis S
        • Alamanni F
        • Fusari M
        • Bona V
        • Tamborini G
        • Muratori M
        • Ballerini G
        • Fiorentini C
        • Biglioli P
        • Pepi M.
        Feasibility and accuracy of a comprehensive multidetector computed tomography acquisition for patients referred for balloon-expandable transcatheter aortic valve implantation.
        Am Heart J. 2011; 161: 1106-1113
        • Harris BS
        • De Cecco CN
        • Schoepf UJ
        • Steinberg DH
        • Bayer RR
        • Krazinski AW
        • Dyer KT
        • Sandhu MK
        • Zile MR
        • Meinel FG.
        Dual-source CT imaging to plan transcatheter aortic valve replacement: accuracy for diagnosis of obstructive coronary artery disease.
        Radiology. 2015; 275: 80-88
        • van den Boogert TPW
        • Vendrik J
        • Claessen BEPM
        • Baan J
        • Beijk MA
        • Limpens J
        • Boekholdt SAM
        • Hoek R
        • Planken RN
        • Henriques JP.
        CTCA for detection of significant coronary artery disease in routine TAVI work-up: A systematic review and meta-analysis.
        Neth Heart J. 2018; 26: 591-599
        • Tota-Maharaj R
        • Blaha MJ
        • McEvoy JW
        • Blumenthal RS
        • Muse ED
        • Budoff MJ
        • Shaw LJ
        • Berman DS
        • Rana JS
        • Rumberger J
        • Callister T
        • Rivera J
        • Agatston A
        • Nasir K.
        Coronary artery calcium for the prediction of mortality in young adults <45 years old and elderly adults >75 years old.
        Eur Heart J. 2012; 33: 2955-2962
        • Kuller LH
        • Lopez OL
        • Mackey RH
        • Rosano C
        • Edmundowicz D
        • Becker JT
        • Newman AB.
        Subclinical cardiovascular disease and death, dementia, and coronary heart disease in patients 80+ years.
        J Am Coll Cardiol. 2016; 67: 1013-1022
        • Agatston AS
        • Janowitz WR
        • Hildner FJ
        • Zusmer NR
        • Viamonte Jr, M
        • Detrano R.
        Quantification of coronary artery calcium using ultrafast computed tomography.
        J Am Coll Cardiol. 1990; 15: 827-832
        • Leening MJ
        • Vedder MM
        • Witteman JC
        • Pencina MJ
        • Steyerberg EW.
        Net reclassification improvement: computation, interpretation, and controversies: a literature review and clinician's guide.
        Ann Intern Med. 2014; 160: 122-131
        • Pencina MJ
        • D'Agostino Sr, RB
        • Demler OV.
        Novel metrics for evaluating improvement in discrimination: net reclassification and integrated discrimination improvement for normal variables and nested models.
        Stat Med. 2012; 31: 101-113
        • Al'Aref SJ
        • Maliakal G
        • Singh G
        • van Rosendael AR
        • Ma X
        • Xu Z
        • Alawamlh OAH
        • Lee B
        • Pandey M
        • Achenbach S
        • Al-Mallah MH
        • Andreini D
        • Bax JJ
        • Berman DS
        • Budoff MJ
        • Cademartiri F
        • Callister TQ
        • Chang HJ
        • Chinnaiyan K
        • Chow BJW
        • Cury RC
        • DeLago A
        • Feuchtner G
        • Hadamitzky M
        • Hausleiter J
        • Kaufmann PA
        • Kim YJ
        • Leipsic JA
        • Maffei E
        • Marques H
        • Gonçalves PA
        • Pontone G
        • Raff GL
        • Rubinshtein R
        • Villines TC
        • Gransar H
        • Lu Y
        • Jones EC
        • Peña JM
        • Lin FY
        • Min JK
        • Shaw LJ.
        Machine learning of clinical variables and coronary artery calcium scoring for the prediction of obstructive coronary artery disease on coronary computed tomography angiography: analysis from the CONFIRM registry.
        Eur Heart J. 2020; 41: 359-367
        • Winther S
        • Schmidt SE
        • Mayrhofer T
        • Bøtker HE
        • Hoffmann U
        • Douglas PS
        • Wijns W
        • Bax J
        • Nissen L
        • Lynggaard V
        • Christiansen JJ
        • Saraste A
        • Bøttcher M
        • Knuuti J.
        Incorporating coronary calcification Into pre-test assessment of the likelihood of coronary artery disease.
        J Am Coll Cardiol. 2020; 76: 2421-2432
        • Brodoefel H
        • Burgstahler C
        • Tsiflikas I
        • Reimann A
        • Schroeder S
        • Claussen CD
        • Heuschmid M
        • Kopp AF.
        Dual-source CT: effect of heart rate, heart rate variability, and calcification on image quality and diagnostic accuracy.
        Radiology. 2008; 247: 346-355
        • Yan RT
        • Miller JM
        • Rochitte CE
        • Dewey M
        • Niinuma H
        • Clouse ME
        • Vavere AL
        • Brinker J
        • Lima JA
        Arbab-Zadeh A. Predictors of inaccurate coronary arterial stenosis assessment by CT angiography.
        JACC Cardiovasc Imaging. 2013; 6: 963-972
        • Ong TK
        • Chin SP
        • Liew CK
        • Chan WL
        • Seyfarth MT
        • Liew HB
        • Rapaee A
        • Fong YY
        • Ang CK
        • Sim KH.
        Accuracy of 64-row multidetector computed tomography in detecting coronary artery disease in 134 symptomatic patients: influence of calcification.
        Am Heart J. 2006; 151 ((:1323.e1–1323.e6)
        • Virmani R
        • Burke AP
        • Farb A
        • Kolodgie FD.
        Pathology of the vulnerable plaque.
        J Am Coll Cardiol. 2006; 47: C13-C18
        • Mark DB
        • Berman DS
        • Budoff MJ
        • Carr JJ
        • Gerber TC
        • Hecht HS
        • Hlatky MA
        • Hodgson JM
        • Lauer MS
        • Miller JM
        • Morin RL
        • Mukherjee D
        • Poon M
        • Rubin GD
        • Schwartz RS
        • American College of Cardiology Foundation Task Force on Expert Consensus Documents
        ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents.
        Circulation. 2010; 121: 2509-2543
        • von Ziegler F
        • Greif M
        • Tittus J
        • Schenzle J
        • Becker C
        • Becker A.
        Distribution of coronary calcifications in patients with suspected coronary heart disease.
        Am Heart J. 2014; 167: 568-575
        • Elias-Smale SE
        • Proença RV
        • Koller MT
        • Kavousi M
        • van Rooij FJ
        • Hunink MG
        • Steyerberg EW
        • Hofman A
        • Oudkerk M
        • Witteman JC.
        Coronary calcium score improves classification of coronary heart disease risk in the elderly: the Rotterdam study.
        J Am Coll Cardiol. 2010; 56: 1407-1414
        • Raggi P
        • Gongora MC
        • Gopal A
        • Callister TQ
        • Budoff M
        • Shaw LJ.
        Coronary artery calcium to predict all-cause mortality in elderly men and women.
        J Am Coll Cardiol. 2008; 52: 17-23
        • Jaarsma C
        • Leiner T
        • Bekkers SC
        • Crijns HJ
        • Wildberger JE
        • Nagel E
        • Nelemans PJ
        • Schalla S.
        Diagnostic performance of noninvasive myocardial perfusion imaging using single-photon emission computed tomography, cardiac magnetic resonance, and positron emission tomography imaging for the detection of obstructive coronary artery disease: a meta-analysis.
        J Am Coll Cardiol. 2012; 59: 1719-1728
        • Rumberger JA
        • Sheedy PF
        • Breen JF
        • Schwartz RS.
        Electron beam computed tomographic coronary calcium score cutpoints and severity of associated angiographic lumen stenosis.
        J Am Coll Cardiol. 1997; 29: 1542-1548