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Original Investigation
October 27, 2021

Association of Age With the Diagnostic Value of Coronary Artery Calcium Score for Ruling Out Coronary Stenosis in Symptomatic Patients

Author Affiliations
  • 1Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
  • 2Johns Hopkins, Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland
  • 3Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
  • 4Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
  • 5Department of Cardiology, University Hospital of Southwest Jutland and Institute of Regional Health Research, University of Southern Denmark, Denmark
  • 6Department of Cardiology, Lillebaelt Hospital-Vejle, Vejle, Denmark
  • 7Dalio Institute of Cardiovascular Imaging, Weill Cornell Medicine, New York, New York
  • 8Department of Radiology, St Paul’s Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
JAMA Cardiol. 2022;7(1):36-44. doi:10.1001/jamacardio.2021.4406
Key Points

Question  What is the diagnostic value of a coronary artery calcium (CAC) score of 0 to rule out obstructive coronary artery disease (CAD)?

Findings  In this cohort study of 23 759 symptomatic patients with obstructive CAD, the prevalence of a CAC score of 0 differed markedly by age group and ranged from 58% in patients who were younger than 40 years to 5% among patients who were 70 years or older. The added diagnostic value of a CAC score of 0 was small in younger patients and greater in older patients.

Meaning  This study found that a sizable proportion of obstructive CAD occurred among younger patients without CAC.

Abstract

Importance  The diagnostic value is unclear of a 0 coronary artery calcium (CAC) score to rule out obstructive coronary artery disease (CAD) and near-term clinical events across different age groups.

Objective  To assess the diagnostic value of a CAC score of 0 for reducing the likelihood of obstructive CAD and to assess the implications of such a CAC score and obstructive CAD across different age groups.

Design, Setting, and Participants  This cohort study obtained data from the Western Denmark Heart Registry and had a median follow-up time of 4.3 years. Included patients were aged 18 years or older who underwent computed tomography angiography (CTA) between January 1, 2008, and December 31, 2017, because of symptoms that were suggestive of CAD. Data analysis was performed from April 5 to July 7, 2021.

Exposures  Obstructive CAD, which was defined as 50% or more luminal stenosis.

Main Outcomes and Measures  Proportion of individuals with obstructive CAD who had a CAC score of 0. Risk-adjusted diagnostic likelihood ratios were used to assess the diagnostic value of a CAC score of 0 for reducing the likelihood of obstructive CAD beyond clinical variables. Risk factors associated with myocardial infarction and death were estimated.

Results  A total of 23 759 symptomatic patients, of whom 12 771 (54%) had a CAC score of 0, were included. This cohort had a median (IQR) age of 58 (49-65) years and was primarily composed of women (13 160 [55%]). Overall, the prevalence of obstructive CAD was relatively low across all age groups, ranging from 3% (39 of 1278 patients) in those who were younger than 40 years to 8% (52 of 619) among those who were 70 years or older. In patients with obstructive CAD, 14% (725 of 5043) had a CAC score of 0, and the prevalence varied across age groups from 58% (39 of 68) among those who were younger than 40 years, 34% (192 of 562) among those aged 40 to 49 years, 18% (268 of 1486) among those aged 50 to 59 years, 9% (174 of 1963) among those aged 60 to 69 years, to 5% (52 of 964) among those who were 70 years or older. The added diagnostic value of a CAC score of 0 decreased at a younger age, with a risk factor–adjusted diagnostic likelihood ratio of a CAC score of 0 ranging from 0.68 (approximately 32% lower likelihood of obstructive CAD than expected) in those who were younger than 40 years to 0.18 (approximately 82% lower likelihood than expected) in those who were 70 years or older. The presence of obstructive vs nonobstructive CAD among those with a CAC score of 0 was associated with a multivariable adjusted hazard ratio of 1.51 (95% CI, 0.98-2.33) for myocardial infarction and all-cause death; however, this hazard ratio varied from 1.80 (95% CI, 1.02-3.19) in those who were younger than 60 years to 1.24 (95% CI, 0.64-2.39) in those who were 60 years or older.

Conclusions and Relevance  This cohort study found that the diagnostic value of a CAC score of 0 to rule out obstructive CAD beyond clinical variables was dependent on age, with the added diagnostic value being smaller for younger patients. In symptomatic patients who were younger than 60 years, a sizable proportion of obstructive CAD occurred among those without CAC and was associated with an increased risk of myocardial infarction and all-cause death.

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