The effect of coronary calcifications on interpretation of non-invasive investigations for coronary artery disease in patients with typical chest pain

Coronary artery disease (CAD) is the most common cause of mortality. Invasive coronary angiography remains the gold standard for the diagnosis of patients with stable CAD and acute coronary syndromes (ACS). However, the accurate diagnosis of CAD is complex and may involve a number of different investigations, including non-invasive techniques, primarily based on patient symptoms. The aim of this thesis was to investigate the prediction of CAD from coronary calcium scoring using multi-detector computed tomography (MDCT) against exercise treadmill testing (ETT [n=360]), myocardial perfusion imaging using magnetic resonance imaging (CMR [n=120]), and myocardial ischaemia assessed using Dobutamine stress echocardiography (DSE [n=35]) in a retrospective cohort of patients with typical chest pain. All 515 patients underwent conventional coronary angiography within 1-month of their non-invasive investigations. The results of this thesis demonstrated that MDCT is more accurate than ETT in identifying significant CAD, whereas a negative ETT was accurate in excluding CAD, as such the two investigations are complementary. Compared to CMR, MDCT was more accurate in detecting significant CAD. However, the burden of perfusion defects during stress was associated with a progressive increase in CAC in patients with non-obstructive CAD only. Finally, DSE was abnormal in patients with non-significant coronary stenosis but with high CAC and a positive ETT, which may suggest microvascular disease. In addition, resting wall motion abnormalities on echocardiography was associated with coronary calcification by MDCT. Non-invasive techniques for the assessment, diagnosis and treatment of CAD remains an integral component for the investigation of chest pain. Future research is required to investigate the relative importance of non-invasive assessments of CAD with respect to coronary intervention, adverse cardiovascular outcomes and all-cause mortality.