Coronary calcium to rule out obstructive coronary artery disease in patients with non-anginal chest pain

BACKGROUND: The use of coronary artery calcium score (CACS) to rule out obstructive coronary artery disease (CAD) remains debated, with performance differing across symptomatic patient subgroups. However, in patients with non-anginal chest pain, CACS may be particularly effective in identifying those who can be deferred from further testing. OBJECTIVES: To investigate the ability of zero CACS to rule out obstructive CAD in a large cohort of patients presenting with non-anginal chest pain. METHODS: Consecutive patients with non-anginal chest pain who were referred for coronary computed tomography angiography (CCTA) were retrospectively included. Obstructive CAD was defined as ≥1 vessel with ≥50% stenosis on CCTA. Hemodynamically significant CAD was defined as CT-FFR ≤0.80. RESULTS: The study included 3212 patients (age 57 ± 10 years; 59% male). Among the 1404 patients (43.7%) with zero CACS, only 7 (0.5%) had obstructive CAD, resulting in a NPV of zero CACS to rule out obstructive CAD of 99.5%. Two patients (0.1%) exhibited hemodynamically significant CAD, resulting in an NPV of zero CACS of 99.9%. Finally, only one patient (0.7‰) was revascularized. Consequently, among patients with zero CACS, the number needed to test with CCTA was 201 to detect one with obstructive CAD, 702 to detect one with hemodynamically significant CAD, and 1404 to identify one requiring revascularization. CONCLUSIONS: In a large cohort of patients with non-anginal chest pain who were referred for CCTA, zero CACS offers excellent rule-out capabilities for obstructive CAD and may be used to defer patients from further testing with CCTA.