Coronary CT may be best diagnostic strategy when evaluating stable chest pain
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Key takeaways:
- Coronary CTA is as useful as direct invasive coronary angiography when evaluating stable chest pain.
- Coronary CT may be associated with a reduction in CV death and MI vs. other noninvasive testing.
For adults with stable chest pain, coronary CTA may be as useful as direct invasive coronary angiography and may be the best diagnostic strategy vs. stress testing and single-photon emission CT myocardial perfusion imaging, data show.
“The diagnostic assessment of stable chest pain is a public health and economic challenge,” Francesco Burzotta, MD, PhD, director of the valve heart diseases clinical pathway, head of the stable heart diseases unit and senior interventional cardiologist at Gemelli University Hospital in Rome and assistant professor at the Institute of Cardiology at Catholic University of the Sacred Heart in Rome, and colleagues wrote in Annals of Internal Medicine. “Although functional testing has been the mainstay in the initial evaluation of patients with suspected stable CAD, its poor sensitivity in detecting obstructive CAD has given way to the advent of alternative diagnostic strategies.”
Image: Adobe Stock
Strategies to diagnose stable chest pain include exercise ECG, wall motion abnormalities measured via stress cardiac MRI or stress echocardiography, perfusion changes assessed via stress SPECT myocardial perfusion imaging (MPI) and coronary CTA.
“Data collected in the randomized trials pooled and summarized in our study suggest that a noninvasive anatomic assessment of the coronary tree by CT scan might be a reasonable approach in patients with suspected stable ischemic heart disease,” Burzotta told Healio. “Since ‘functional’ assessment of myocardial ischemia has established clinical value, such findings open the door to further evaluations regarding the specific workup in ischemic heart disease patients according to their different possible clinical features.”
Multiple comparisons
The researchers conducted a meta-analysis of 15 randomized controlled trials comparing diagnostic strategies for CAD detection to assess their effect on clinical management and subsequent health effects. Four trials compared coronary CT vs. invasive coronary angiography (n = 5,752; mean follow-up, 2 years); two trials compared coronary CT vs. exercise ECG (n = 3,783; mean follow-up, 3 years); five trials compared coronary CT vs. SPECT-MPI (n = 10,195; mean follow-up, 1 year); two trials compared SPECT-MPI vs. exercise ECG (n = 1,229; mean follow-up, 2 years); one trial compared SPECT-MPI vs. cardiac MRI (n = 962; mean follow-up, 1 year); and one trial compared stress echocardiography vs. exercise ECG (n = 385; mean follow-up, 3 years).
Researchers found that the strongest available evidence was for three of the six comparisons: coronary CTA vs. invasive coronary angiography, coronary CT vs. exercise ECG and coronary CT vs. SPECT-MPI.
Compared with direct invasive coronary angiography referral, coronary CT was associated with no difference in CV death and MI, with an RR of 0.84 (95% CI, 0.52-1.35; low certainty) but less index invasive coronary angiography (RR = 0.23; 95% CI, 0.22-0.25; high certainty) and index revascularization (RR = 0.71; 95% CI, 0.63-0.8; moderate certainty).
Additionally, researchers found that coronary CT was associated with a reduction in CV death and MI compared with exercise ECG (RR = 0.66; 95% CI, 0.44-0.99; moderate certainty) and SPECT-MPI (RR = 0.64; 95% CI, 0.45-0.9; high certainty). In addition, coronary CT was associated with more index revascularization (RR = 1.78; 95% CI, 1.33-2.38; moderate certainty) but less downstream testing (RR = 0.56; 95% CI, 0.45-0.71; very low certainty) compared with exercise ECG.
“Data collected suggest that CT coronary angiography might gain a central role in the diagnostic workup of patients with ischemic heart disease,” Burzotta told Healio. “This requires important adjustments in the organization of cardiovascular departments.”
Further research needed
The researchers noted that most comparisons primarily relied on a single study and that many studies were underpowered to detect potential differences in direct health outcomes. Individual patient data were also lacking.
“Coronary CT angiography was associated with similar risk for CV death and MI compared with direct invasive coronary angiography referral and with a reduction in the risk for CV death and MI compared with exercise ECG and SPECT-MPI,” the researchers wrote. “[The] results’ uncertainty calls for further research to better assess the relative performance of each diagnostic strategy.”
For more information:
Francesco Burzotta, MD, PhD, can be reached at francesco.burzotta@unicatt.it.
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