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Diagnostic and Prognostic Value of Absence of Coronary Artery Calcification

Ammar Sarwar, MD^_*, Leslee J. Shaw, PhD, Michael D. Shapiro, DO^_*, Ron Blankstein, MD^_*, Udo Hoffman, MD, MPH^_*, Ricardo C. Cury, MD^_*, Suhny Abbara, MD^_*, Thomas J. Brady, MD^_*, Matthew J. Budoff, MD, Roger S. Blumenthal, MD, Khurram Nasir, MD, MPH^_*,_*,,||

^_* Cardiac PET CT MRI Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Department of Cardiology, Emory University, Atlanta, Georgia
Los Angeles Biomedical Research Institute at Harbor—University of California Los Angeles, Los Angeles, California
Ciccarone Preventive Cardiology Center, Johns Hopkins University, School of Medicine, Baltimore, Maryland
^|| Department of Internal Medicine, Boston Medical Center, Boston, Massachusetts

^_* Reprint requests and correspondence: Dr. Khurram Nasir, Division of Cardiology, Johns Hopkins University, Baltimore, Maryland 21287 (Email: knasir1{at}jhmi.edu).

Objectives: In this study, we systematically assessed the diagnostic and prognostic value of absence of coronary artery calcification (CAC) in asymptomatic and symptomatic individuals.

Background: Presence of CAC is a well-established marker of coronary plaque burden and is associated with a higher risk of adverse cardiovascular outcomes. Absence of CAC has been suggested to be associated with a very low risk of significant coronary artery disease, as well as minimal risk of future events.

Methods: We searched online databases (e.g., PubMed and MEDLINE) for original research articles published in English between January 1990 and March 2008 examining the diagnostic and prognostic utility of CAC.

Results: A systematic review of published articles revealed 49 studies that fulfilled our criteria for inclusion. These included 13 studies assessing the relationship of CAC with adverse cardiovascular outcomes in 64,873 asymptomatic patients. In this cohort, 146 of 25,903 patients without CAC (0.56%) had a cardiovascular event during a mean follow-up period of 51 months. In the 7 studies assessing the prognostic value of CAC in a symptomatic population, 1.80% of patients without CAC had a cardiovascular event. Overall, 18 studies demonstrated that the presence of any CAC had a pooled sensitivity and negative predictive value of 98% and 93%, respectively, for detection of significant coronary artery disease on invasive coronary angiography. In 4,870 individuals undergoing myocardial perfusion and CAC testing, in the absence of CAC, only 6% demonstrated any sign of ischemia. Finally, 3 studies demonstrated that absence of CAC had a negative predictive value of 99% for ruling out acute coronary syndrome.

Conclusions: On the basis of our review of more than 85,000 patients, we conclude that the absence of CAC is associated with a very low risk of future cardiovascular events, with modest incremental value of other diagnostic tests in this very low-risk group.

Key Words: computed tomography • coronary calcification • outcomes • meta-analysis

Abbreviations and Acronyms   ACC = American College of Cardiology   ACS = acute coronary syndromes   AHA = American Heart Association   CAC = coronary artery calcium   CAD = coronary artery disease   CI = confidence interval   CT = computed tomography   ICA = invasive coronary angiography   LDL = low-density lipoprotein   MPS = myocardial perfusion scans

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