Coronary artery calcification detection with invasive coronary angiography in comparison with unenhanced computed tomography

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The presence of extensive coronary artery calcifications (CAC) influences treatment decisions, particularly for revascularization. However, important CAC might be missed with invasive coronary angiography (ICA). Our aim was to determine the accuracy of ICA in the identification of CAC using computed tomography (CT) as reference standard.

Patients and methods

Overall, 349 consecutive patients who underwent both CT-based CAC-scoring and invasive coronary angiography within 60 days were retrospectively included. Two experienced operators classified CAC on ICA, without knowledge of CT-based CAC scoring, for each of the four main vessels as (0) absent, (1) mild, (2) moderate, or (3) dense calcifications. These scores were correlated with the CT-based Agatston CAC-scores, the noninvasive reference standard. The sensitivity, specificity, and accuracy of identified CAC using ICA were derived. Calcifications identified as moderate or dense on ICA or with a vessel-based Agatston score of more than 100 were considered important.


CT classified 671 (48%) of the 1396 vessels as having moderately or densely calcified vessels (Agatston score >100), whereas this was 137 (9.8%) using ICA (P<0.001). A significant correlation was found between the CT-based and ICA-based CAC-scores for all vessels (P<0.001). The sensitivity in detecting any CAC by means of ICA was 43% with a specificity of 92% and an accuracy of 55%. The sensitivity of important CAC identification by ICA was 19%, the specificity 99%, and the accuracy 61%.


The accuracy of ICA for the identification of calcifications is very low as only 19% of the relevant calcifications was identified. Preprocedural assessment of CAC with CT could be considered to improve the treatment approach.

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