• Tarun K Mittal, Alison Pottle, Ed Nicol, Mahmoud Barbir, Ben Ariff, Saeed Mirsadraee, Michael Dubowitz, Diana A Gorog, Piers Clifford, Soroosh Firoozan, Robert Smith, Simon Dubrey, Harmeet Chana, Jaymin Shah, Nigel Stephens, Christopher Travill, Andrew Kelion, Mini Pakkal, and Adam Timmis.
• Department of Cardiology and Imaging, Royal Brompton and Harefield NHS Foundation Trust, London UB9 6JH, UK.
• Eur Heart J Cardiovasc Imaging. 2017 May 1; 18 (8): 922-929.

AimsCT calcium scoring (CTCS) and CT cardiac angiography (CTCA) are widely used in patients with stable chest pain to exclude significant coronary artery disease (CAD). We aimed to resolve uncertainty about the prevalence of obstructive coronary artery disease and long-term outcomes in patients with a zero-calcium score (ZCS).Methods And ResultsConsecutive patients with stable cardiac symptoms referred for CTCS or CTCS and CTCA from chest pain clinics to a tertiary cardiothoracic centre were prospectively enrolled. In those with a ZCS, the prevalence of obstructive CAD on CTCA was determined. A follow-up for all-cause mortality was obtained from the NHS tracer service. A total of 3914 patients underwent CTCS of whom 2730 (69.7%) also had a CTCA. Half of the patients were men (50.3%) with a mean age of 56.9 years. Among patients who had both procedures, a ZCS was present in 52.2%, with a negative predictive value of 99.5% for excluding ≥70% stenosis on CTCA. During a mean follow-up of 5.2 years, the annual event rate was 0.3% for those with ZCS compared with 1.2% for CS ≥1. The presence of non-calcified atheroma on CTCA in patients with ZCS did not affect the prognostic value (P = 0.98).ConclusionIn patients with stable symptoms and a ZCS, obstructive CAD is rare, and prognosis over the long-term is excellent, regardless of whether non-calcified atheroma is identified. A ZCS could reliably be used as a 'gatekeeper' in this patient cohort, obviating the need for further more expensive tests.© The Author 2017. Published by Oxford University Press on behalf of the European Society of Cardiology

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