The role of chest pain symptoms in predicting coronary artery disease severity and MACE events in patients with zero CAC: a study from a large CCTA cohort.

Coronary artery calcium (CAC) is a well-established predictor of major adverse cardiovascular events (MACE) and is considered a key marker in the assessment of coronary artery disease (CAD). While its prognostic value has been extensively validated in asymptomatic populations, its utility in symptomatic patients, particularly those with CAD, remains underutilized. To examine the relationship between chest pain symptoms, CAD severity, and the risk of MACE in patients with a zero CAC score. A cohort of 10,908 patients with a zero CAC score underwent coronary computed tomography angiography (CCTA). The cohort was stratified by chest pain symptoms into three groups: no chest pain, atypical chest pain, and typical angina. CCTA findings, CAD severity, and the incidence of MACE were assessed over a median follow-up period of 3.54 years. The cohort had a mean age of 53.83 ± 10.19 years, with 130 patients (1.19%) experiencing MACE. The typical angina group exhibited the highest MACE rate (3.90%), followed by the atypical chest pain (1.48%) and no chest pain groups (0.62%). CCTA findings showed that patients with typical angina had the highest proportion of obstructive CAD (27.08%). Multivariable analysis identified typical angina as a significant independent predictor of obstructive CAD (odds ratio [OR] = 4.827, 95% CI: 3.807, 6.122, p < 0.001). Typical angina was also associated with an increased MACE risk (hazard ratio [HR] = 8.540, 95% CI: 5.304, 13.736, p < 0.001). In patients with obstructive CAD, typical angina exhibited the highest MACE rate (9.47%, MACE/year 4.00%), with an HR of 7.623 (95% CI: 3.593, 16.175, p < 0.001). Chest pain, particularly typical angina, is a significant predictor of both obstructive CAD and MACE risk in patients with a zero CAC score. In symptomatic patients, the risk should still be considered even if the CAC score is zero.