National Heart Centre Singapore, SG.
Glob Heart. 2020 Mar 3;15(1):22. doi: 10.5334/gh.766.
Chest pain is a common symptom for cardiology referrals. The ACC-AHA guidelines recommend exercise stress electrocardiography (TMX) as the initial diagnostic test. However, the TMX only has moderate sensitivity and non-diagnostic cases may require further stress imaging studies. In this study we aimed to look at the feasibility of combining coronary artery calcium (CAC) score with TMX to refine risk stratification. This may be an alternative to stress imaging in cases of non low-risk TMX, with the added advantage of short time turnaround time and low radiation dose.
A total of 145 patients who presented consecutively to the National Heart Centre Singapore with chest pain were included in this study. These were intermediate risk patients with an average Duke Clinical Score of 38.8%. All patients underwent both TMX and computed tomography scan of the coronary arteries (CTCA) which also includes CAC. The primary outcome was defined as obstructive coronary artery disease i.e. >50% left main artery stenosis and/or >70% stenosis in other epicardial arteries.
The combination of TMX and CAC was comparable to stress imaging in detecting obstructive coronary artery disease. When added to TMX, CAC has an integrated discriminative improvement of 74.1%, achieved an area under the curve of 0.974 and adjusted R2 of 0.670 in detecting the primary outcome.
The strategy of combining TMX and CAC is feasible in clinical practice to refine risk stratification in outpatients with intermediate risk chest pain. The calcium score readout also further guides therapy for primary prevention.
Treadmill exercise is one of the first line tests for cardiac chest pain work up.Non diagnostic test treadmill results requires further adjunctive tests.Downstream stress imaging causes delay in time to diagnosis.Coronary artery calcium scoring needs minimal preparation with fast turnaround time.Addition of coronary artery calcium to treadmill performs comparably to stress imaging.This is a feasible alternative to risk stratify non diagnostic treadmill tests and guide therapy for primary prevention.
胸痛是心内科转诊的常见症状。ACC-AHA 指南推荐运动负荷心电图（TMX）作为初始诊断测试。然而，TMX 的敏感性仅为中等，非诊断性病例可能需要进一步进行应激成像研究。在这项研究中，我们旨在研究将冠状动脉钙（CAC）评分与 TMX 相结合以细化风险分层的可行性。这可能是 TMX 低风险情况下替代应激成像的一种方法，其优点是周转时间短且辐射剂量低。
本研究共纳入 145 例连续就诊于新加坡国家心脏中心的胸痛患者。这些患者为平均 Duke 临床评分 38.8%的中危患者。所有患者均接受 TMX 和冠状动脉计算机断层扫描（CTCA）检查，包括 CAC。主要结局定义为阻塞性冠状动脉疾病，即左主干动脉狭窄>50%和/或其他心外膜动脉狭窄>70%。
TMX 和 CAC 的联合检测与应激成像在检测阻塞性冠状动脉疾病方面具有可比性。当添加到 TMX 时，CAC 的综合判别改善率为 74.1%，曲线下面积为 0.974，调整后的 R2 为 0.670，可用于检测主要结局。
在门诊中危胸痛患者中，结合 TMX 和 CAC 进行风险分层是可行的策略。钙评分结果还进一步指导了一级预防的治疗。
跑步机运动是心脏胸痛检查的一线测试之一。非诊断性 TMX 测试结果需要进一步的辅助测试。下游应激成像会导致诊断时间延迟。冠状动脉钙评分只需最少的准备，周转时间快。将冠状动脉钙添加到跑步机测试中，与应激成像相比表现相当。这是一种替代非诊断性 TMX 测试进行风险分层并指导一级预防治疗的可行方法。
