From the Guidelines
The odds of having a heart attack with atypical chest pain and a recent coronary calcium CT score of zero are very low, generally less than 1% over the next 5-10 years. A calcium score of zero indicates no detectable calcified plaque in the coronary arteries, which is highly reassuring, as noted in the 2022 study by the American College of Radiology 1. This finding essentially places you in a low-risk category for coronary events, even with your symptoms of atypical chest pain. However, it's essential to understand that a zero calcium score doesn't completely eliminate risk, as non-calcified plaque can still be present, particularly in younger patients, as discussed in the 2012 ACCF/AHA guideline 1. If your chest pain persists, further evaluation may be warranted to investigate other potential causes such as:
- Gastroesophageal reflux disease
- Musculoskeletal issues
- Anxiety The calcium score is particularly valuable as a risk stratification tool because coronary calcification correlates strongly with total plaque burden and future cardiac events, as highlighted in the 2022 update by the American College of Radiology 1. Lifestyle modifications, including:
- Regular exercise
- Heart-healthy diet
- Smoking cessation
- Management of other cardiovascular risk factors like hypertension or diabetes remain important even with a zero calcium score to maintain your low-risk status. It's also worth noting that the absence of coronary calcification does not exclude obstructive stenosis, as demonstrated in the CORE-64 trial, but the negative predictive value of a zero calcium score for obstructive CAD is high, as shown in the PROMISE trial 1.
From the Research
Odds of Atypical Chest Pain with a Recently Coronary Calcium CT Score of Zero Having a Heart Attack
- The odds of atypical chest pain with a recently coronary calcium CT score of zero having a heart attack are not directly stated in the provided studies.
- However, a study published in 2021 2 found that the addition of the coronary artery calcium (CAC) score to diagnostic models improved the ability to safely rule out obstructive coronary artery disease (CAD) and identified patients at high risk for future coronary artery events.
- Another study published in 2014 3 found that patients with atypical chest pain and diabetes mellitus showed more extensive CAD, as well as more obstructive CAD, particularly in women.
- A study published in 2019 4 found that a medical history of gastroesophageal reflux disease (GERD) was frequently observed in approximately one-fifth of patients with vasospastic angina, indicating that vasospastic angina may be present in patients with chest pain and a medical history of GERD.
- It is also worth noting that a study published in 1997 5 found that 10% to 50% of patients with atypical chest pain suggestive of cardiac disease may have GERD as the cause of their pain.
Risk Factors for Coronary Atherosclerosis
- A study published in 2022 6 found that the risk factors for a high coronary artery calcium score (CACS) in GERD patients included age, male sex, hypertension, and hypercholesterolemia.
- The same study found that the presence of a high CACS did not increase the risk of GERD, nor did the presence of GERD increase the risk of a high CACS.
Diagnostic Accuracy
- The study published in 2021 2 found that the addition of the CAC score to diagnostic models improved diagnostic accuracy and risk stratification.
- The study published in 2014 3 found that coronary CT angiography (CCTA) was accurate in the detection of CAD, and that CAD characteristics such as the number of affected segments, obstructive CAD, and CAD distribution could be compared on a per patient and segment basis.