Clinical Research
Cardiac Imaging
Diagnostic Accuracy of Computed Tomography Coronary Angiography According to Pre-Test Probability of Coronary Artery Disease and Severity of Coronary Arterial Calcification: The CORE-64 (Coronary Artery Evaluation Using 64-Row Multidetector Computed Tomography Angiography) International Multicenter Study

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Objectives

The purpose of this study was to assess the impact of patient population characteristics on accuracy by computed tomography angiography (CTA) to detect obstructive coronary artery disease (CAD).

Background

The ability of CTA to exclude obstructive CAD in patients of different pre-test probabilities and in presence of coronary calcification remains uncertain.

Methods

For the CORE-64 (Coronary Artery Evaluation Using 64-Row Multidetector Computed Tomography Angiography) study, 371 patients underwent CTA and cardiac catheterization for the detection of obstructive CAD, defined as ≥50% luminal stenosis by quantitative coronary angiography (QCA). This analysis includes 80 initially excluded patients with a calcium score ≥600. Area under the receiver-operating characteristic curve (AUC) was used to evaluate CTA diagnostic accuracy compared to QCA in patients according to calcium score and pre-test probability of CAD.

Results

Analysis of patient-based quantitative CTA accuracy revealed an AUC of 0.93 (95% confidence interval [CI]: 0.90 to 0.95). The AUC remained 0.93 (95% CI: 0.90 to 0.96) after excluding patients with known CAD but decreased to 0.81 (95% CI: 0.71 to 0.89) in patients with calcium score ≥600 (p = 0.077). While AUCs were similar (0.93, 0.92, and 0.93, respectively) for patients with intermediate, high pre-test probability for CAD, and known CAD, negative predictive values were different: 0.90, 0.83, and 0.50, respectively. Negative predictive values decreased from 0.93 to 0.75 for patients with calcium score <100 or ≥100, respectively (p = 0.053).

Conclusions

Both pre-test probability for CAD and coronary calcium scoring should be considered before using CTA for excluding obstructive CAD. For that purpose, CTA is less effective in patients with calcium score ≥600 and in patients with a high pre-test probability for obstructive CAD.

Key Words

angiography
coronary artery disease
imaging

Abbreviations and Acronyms

AUC
area under the curve
CAD
coronary artery disease
CI
confidence interval
CTA
computed tomography angiography
QCA
quantitative coronary angiography

Cited by (0)

This investigation was supported by grants from Toshiba Medical Systems; the Doris Duke Charitable Foundation; the National Heart, Lung, and Blood Institute (RO1-HL66075-01 and HO1-HC95162-01); the National Institute on Aging (RO1-AG021570-01); and the Donald W. Reynolds Foundation.

Dr. Arbab-Zadeh serves on the Steering Committee of the CORE-320 study, which is sponsored by Toshiba Medical Systems. Drs. Miller, Paul, and Shapiro have received grant support from Toshiba Medical Systems. Dr. Dewey has received grant support from Toshiba Medical Systems, GE Healthcare, Bracco, Guerbet, European Regional Development Fund, German Heart Foundation/German Foundation of Heart Research, and a joint program from the German Science Foundation (DFG) and the German Federal Ministry of Education and Research (BMBF) for meta-analyses; has received speaker fees from Toshiba Medical Systems, Cardiac MR Academy Berlin, Bayer-Schering and Guerbet; is a consultant for Guerbet; is an editor for Cardiac CT from Springer; and is the Cardiac CT Courses Director in Berlin. Dr. Paul has received speaker fees from Toshiba Medical Systems; and advisory fees from Vital Images. Dr. Hoe has served as Director of the Cardiac CT Training Course sponsored by Toshiba Medical Systems, Asia; has received speaker fees from GE Biosciences, Bayer-Schering Pharma, Infinitt Systems, and Toshiba Medical Systems; and has received research grant support from Toshiba Medical Systems. Dr. Lardo reports receiving grant support from CT Core Laboratory and Toshiba Medical Systems; and speaker fees from Toshiba Medical Systems. Dr. Bush has received speaker fees from Bristol-Myers Squibb, Toshiba Medical Systems, and Sanofi-Aventis. Dr. Lima has received grant support from Toshiba Medical Systems, Bracco Diagnostics, and GE Medical Systems; and has received speaker fees from Toshiba Medical Systems. All other authors have reported they have no relationships relevant to the contents of this paper to disclose. Steven E. Nissen, MD, MACC, served as Guest Editor.