Original Research
Diagnostic and Prognostic Value of Absence of Coronary Artery Calcification

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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

Cited by (0)

Drs. Shapiro, Blankstein, and Nasir have received support from National Institutes of Health grant 1T32 HL076136-02. Dr. H. William Strauss served as Guest Editor.