The Prognostic Value of CAC Zero Among Individuals Presenting With Chest Pain: A Meta-Analysis

Ali M. Agha, Justin Pacor, Gowtham R. Grandhi, Reed Mszar, Safi U. Khan, Roosha Parikh, Tanushree Agrawal, Jeremy Burt, Ron Blankstein, Michael J. Blaha, Leslee J. Shaw, Mouaz H. Al-Mallah, Alexandria Brackett, Miguel Cainzos-Achirica, Edward J. Miller, Khurram Nasir

Research output: Contribution to journalArticlepeer-review

31 Scopus citations


Background: There is little consensus on whether absence of coronary artery calcium (CAC) can identify patients with chest pain (CP) who can safely avoid additional downstream testing. Objectives: The purpose of this study was to conduct a systematic review and meta-analysis investigating the utility of CAC assessment for ruling out obstructive coronary artery disease (CAD) among patients with stable and acute CP, at low-to-intermediate risk of obstructive CAD undergoing coronary computed tomography angiography (CTA). Methods: The authors searched online databases for studies published between 2005 and 2021 examining the relationship between CAC and obstructive CAD (≥50% coronary luminal narrowing) on coronary CTA among patients with stable and acute CP. Results: In this review, the authors included 19 papers comprising 79,903 patients with stable CP and 13 papers including 12,376 patients with acute CP undergoing simultaneous CAC and coronary CTA assessment. Overall, 45% (95% CI: 40%-50%) of patients with stable CP and 58% (95% CI: 50%-66%) of patients with acute CP had CAC = 0. The negative predictive values for CAC = 0 ruling out obstructive CAD were 97% (95% CI: 96%-98%) and 98% (95% CI: 96%-99%) among patients with stable and acute CP, respectively. Additionally, the prevalence of nonobstructive CAD among those with CAC = 0 was 13% (95% CI: 10%-16%) among those with stable CP and 9% (95% CI: 5%-13%) among those with acute CP. A CAC score of zero predicted a low incidence of major adverse cardiac events among patients with stable CP (0.5% annual event rate) and acute CP (0.8% overall event rate). Conclusions: Among over 92,000 patients with stable or acute CP, the absence of CAC was associated with a very low prevalence of obstructive CAD, a low prevalence of nonobstructive CAD, and a low annualized risk of major adverse cardiac events. These findings support the role of CAC = 0 in a value-based health care delivery model as a “gatekeeper” for more advanced imaging among patients presenting with CP.

Original languageEnglish
Pages (from-to)1745-1757
Number of pages13
JournalJACC: Cardiovascular Imaging
Issue number10
StatePublished - Oct 2022
Externally publishedYes


  • atherosclerosis
  • chest pain
  • coronary artery calcium
  • coronary computed tomography angiography


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