Tota-Maharaj Rajesh, McEvoy John W, Blaha Michael J, Silverman Michael G, Nasir Khurram, Blumenthal Roger S
Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Baltimore, MD 21287, USA.
Crit Pathw Cardiol. 2012 Sep;11(3):99-106. doi: 10.1097/HPC.0b013e31825b1429.
Although coronary artery calcium (CAC) scoring has an established role in risk-stratifying asymptomatic patients at intermediate risk of coronary heart disease (CHD), its utility in the evaluation of patients with chest pain is uncertain. We conducted a literature review of articles investigating the utility of: (1) CAC scoring in elective patients with indeterminate chest pain symptoms, (2) CAC as a "gatekeeper" in the triage of patients presenting to the emergency department (ED) with chest pain, and (3) the cost-effectiveness of the use of CAC scoring in the ED. We also evaluated the predictive accuracy of the absence of CAC in a pooled analysis of applicable studies. Only studies evaluating patients classified as low or intermediate risk were included. Low to intermediate risk was established by Framingham risk scores, Thrombolysis in Myocardial Infarction scores, Diamond-Forrester classification, or by the absence of typical angina symptoms, ischemic electrocardiogram, positive cardiac biomarkers, or a prior history of CHD. In our pooled analysis, the presence of any CAC resulted in a high sensitivity (range 70%-100%) for predicting the presence of obstructive coronary disease among symptomatic patients subsequently referred for coronary angiography. More importantly, a CAC score of 0 in low- and intermediate-risk ED populations with chest pain had a high negative predictive value (99.4%) for CHD events over an average follow-up of 21 months. CAC scoring also seems cost-effective in this population. Although further research is needed, carefully selected ED patients with a normal electrocardiogram, normal cardiac biomarkers, and CAC = 0 may be considered for early discharge without further testing.
尽管冠状动脉钙化（CAC）评分在对冠心病（CHD）中度风险的无症状患者进行风险分层方面已确立了作用，但其在胸痛患者评估中的效用尚不确定。我们对以下方面效用的研究文章进行了文献综述：（1）CAC评分在有不确定胸痛症状的择期患者中的应用；（2）CAC作为对因胸痛就诊于急诊科（ED）的患者进行分诊的“把关者”；（3）在ED中使用CAC评分的成本效益。我们还在适用研究的汇总分析中评估了无CAC的预测准确性。仅纳入了评估低风险或中度风险患者的研究。低至中度风险通过弗明汉风险评分、心肌梗死溶栓评分、钻石-弗雷斯特分类法确定，或根据无典型心绞痛症状、缺血性心电图、阳性心脏生物标志物或CHD病史来确定。在我们的汇总分析中，对于随后接受冠状动脉造影的有症状患者，任何CAC的存在对预测阻塞性冠状动脉疾病具有较高的敏感性（范围为70%-100%）。更重要的是，在平均随访21个月期间，胸痛的低风险和中度风险ED人群中CAC评分为0对CHD事件具有较高的阴性预测价值（99.4%）。CAC评分在该人群中似乎也具有成本效益。尽管还需要进一步研究，但对于精心挑选的心电图正常、心脏生物标志物正常且CAC = 0的ED患者，可考虑在不进行进一步检查的情况下早期出院。
