Author + information
- Received March 25, 2019
- Revision received November 27, 2019
- Accepted December 5, 2019
- Published online May 4, 2020.
- Dorine Rijlaarsdam-Hermsen, MDa,b,c,
- Mallory Lo-Kioeng-Shioe, BScc,
- Ron T. van Domburg, PhDc,
- Jaap W. Deckers, MD, PhDc,∗ (, )
- Dirkjan Kuijpers, MD, PhDb and
- Paul R.M. van Dijkman, MD, PhDa
- aHaaglanden Medical Center Bronovo, Department of Cardiology, The Hague, the Netherlands
- bHaaglanden Medical Center Bronovo, Department of Radiology, The Hague, the Netherlands
- cErasmus Medical Center, Department of Cardiology, Rotterdam, the Netherlands
- ↵∗Address for correspondence:
Dr. Jaap W. Deckers, Thoraxcenter, Division of Cardiology, Erasmus Medical Center, ‘s-Gravendijkwal 230, 3015 GD Rotterdam, the Netherlands.
Objectives This study assessed whether adenosine stress-only perfusion cardiac magnetic resonance (CMR) following a positive coronary artery calcium (CAC) score improved the diagnostic yield of invasive coronary angiography (CAG) in patients with stable chest pain. The study also established the association between positive CAC scores and stress-induced myocardial ischemia.
Background The diagnostic yield of catheterization among patients with suspected coronary artery disease (CAD) is low. Improved patient selection and diagnostic testing are necessary. The CAC score can minimize unnecessary diagnostic testing, and in low-risk patients, normal CMR results have a high negative predictive value. Less comprehensive protocols may be sufﬁcient to guide further work-up.
Methods A total of 642 consecutive patients (mean age: 63 years; 50% women) with stable chest pain and CAC scores of >0 who were referred for CMR were enrolled. Patients with a perfusion defect were subsequently examined by CAG. Patients were followed up for 1 year. Outcome was obstructive CAD.
Results Obstructive CAD was present in 12% of patients. For CAD diagnosis, the sensitivity of adenosine CMR was 90.9% (95% confidence interval [CI]: 88.7 to 93.1), specificity was 98.7% (95% CI: 97.9 to 99.6), positive predictive value was 92.0% (95% CI: 89.8 to 94.1), and negative predictive value was 98.6% (95% CI: 97.6 to 99.5). A CAC score between 0.1 and 100 without typical angina was associated with obstructive CAD in only 3% of patients. Patients with nonanginal chest pain and a CAC score ≥400 had obstructive CAD (16%).
Conclusions Stress-only adenosine CMR had high diagnostic accuracy and served as an efficient gatekeeper to CAG in stable patients with a CAC score >0. Patients with CAC scores between 0.1 and 100 could be deferred from further testing in the absence of clinical features that suggested high risk. However, in patients with CAC score ≥400, functional testing should be indicated, regardless of the type of chest pain.
Dr. Rijlaarsdam-Hermsen was supported by an unrestricted grant from the Bronovo Research Foundation. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Cardiovascular Imaging author instructions page.
- Received March 25, 2019.
- Revision received November 27, 2019.
- Accepted December 5, 2019.
- 2020 American College of Cardiology Foundation
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