Impact of coronary calcification assessed by coronary CT angiography on treatment decision in patients with three-vessel CAD: insights from SYNTAX III trial

Daniele Andreini, Kuniaki Takahashi, Saima Mushtaq, Edoardo Conte, Rodrigo Modolo, Jeroen Sonck, Johan De Mey, Paolo Ravagnani, Danny Schoors, Francesco Maisano, Philipp Kaufmann, Wietze Lindeboom, Marie-Angele Morel, Torsten Doenst, Ulf Teichgräber, Gianluca Pontone, Giulio Pompilio, Antonio Bartorelli, Yoshinobu Onuma, Patrick W Serruys

Research output: Contribution to journalArticlepeer-review


OBJECTIVES: The aim of this study was to determine Syntax scores based on coronary computed tomography angiography (CCTA) and invasive coronary angiography (ICA) and to assess whether heavy coronary calcification significantly limits the CCTA evaluation and the impact of severe calcification on heart team's treatment decision and procedural planning in patients with three-vessel coronary artery disease (CAD) with or without left main disease.

METHODS: SYNTAX III was a multicentre, international study that included patients with three-vessel CAD with or without left main disease. The heart teams were randomized to either assess coronary arteries with coronary CCTA or ICA. We stratified the patients based on the presence of at least 1 lesion with heavy calcification defined as arc of calcium >180° within the lesion using CCTA. Agreement on the anatomical SYNTAX score and treatment decision was compared between patients with and without heavy calcifications.

RESULTS: Overall, 222 patients with available CCTA and ICA were included in this trial subanalysis (104 with heavy calcification, 118 without heavy calcification). The mean difference in the anatomical SYNTAX score (CCTA derived-ICA derived) was lower in patients without heavy calcifications [mean (-1.96 SD; +1.96 SD) = 1.5 (-19.3; 22.4) vs 5.9 (-17.5; +29.3), P = 0.004]. The agreement on treatment decision did not differ between patients with (Cohen's kappa 0.79) or without coronary calcifications (Cohen's kappa 0.84). The agreement on the treatment planning did not differ between patients with (concordance 80.3%) or without coronary calcifications (concordance 82.8%).

CONCLUSIONS: An overall good correlation between CCTA- and ICA-derived Syntax score was found. The presence of heavy coronary calcification moderately influenced the agreement between CCTA and ICA on the anatomical SYNTAX score. However, agreement on the treatment decision and planning was high and irrespective of the presence of calcified lesions.

Original languageEnglish
Pages (from-to)176-184
Number of pages9
JournalInteractive Cardiovascular and Thoracic Surgery
Issue number2
Early online date20 Sep 2021
Publication statusPublished - 18 Jan 2022

Bibliographical note

Publisher Copyright:
© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.

This record is sourced from MEDLINE/PubMed, a database of the U.S. National Library of Medicine


  • Coronary calcification
  • Coronary computed tomography angiography
  • Heart team


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