Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data

Abstract

Objective To determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups of patients. Design Prospectively designed meta-analysis of individual patient data from prospective diagnostic accuracy studies. Data sources Medline, Embase, and Web of Science for published studies. Unpublished studies were identified via direct contact with participating investigators. Eligibility criteria for selecting studies Prospective diagnostic accuracy studies that compared coronary CTA with coronary angiography as the reference standard, using at least a 50% diameter reduction as a cutoff value for obstructive CAD. All patients needed to have a clinical indication for coronary angiography due to suspected CAD, and both tests had to be performed in all patients. Results had to be provided using 2×2 or 3×2 cross tabulations for the comparison of CTA with coronary angiography. Primary outcomes were the positive and negative predictive values of CTA as a function of clinical pretest probability of obstructive CAD, analysed by a generalised linear mixed model; calculations were performed including and excluding non-diagnostic CTA results. The no-treat/treat threshold model was used to determine the range of appropriate pretest probabilities for CTA. The threshold model was based on obtained post-test probabilities of less than 15% in case of negative CTA and above 50% in case of positive CTA. Sex, angina pectoris type, age, and number of computed tomography detector rows were used as clinical variables to analyse the diagnostic performance in relevant subgroups. Results Individual patient data from 5332 patients from 65 prospective diagnostic accuracy studies were retrieved. For a pretest probability range of 7-67%, the treat threshold of more than 50% and the no-treat threshold of less than 15% post-test probability were obtained using CTA. At a pretest probability of 7%, the positive predictive value of CTA was 50.9% (95% confidence interval 43.3% to 57.7%) and the negative predictive value of CTA was 97.8% (96.4% to 98.7%); corresponding values at a pretest probability of 67% were 82.7% (78.3% to 86.2%) and 85.0% (80.2% to 88.9%), respectively. The overall sensitivity of CTA was 95.2% (92.6% to 96.9%) and the specificity was 79.2% (74.9% to 82.9%). CTA using more than 64 detector rows was associated with a higher empirical sensitivity than CTA using up to 64 rows (93.4% v 86.5%, P=0.002) and specificity (84.4% v 72.6%, P<0.001). The area under the receiver-operating-characteristic curve for CTA was 0.897 (0.889 to 0.906), and the diagnostic performance of CTA was slightly lower in women than in with men (area under the curve 0.874 (0.858 to 0.890) v 0.907 (0.897 to 0.916), P<0.001). The diagnostic performance of CTA was slightly lower in patients older than 75 (0.864 (0.834 to 0.894), P=0.018 v all other age groups) and was not significantly influenced by angina pectoris type (typical angina 0.895 (0.873 to 0.917), atypical angina 0.898 (0.884 to 0.913), non-anginal chest pain 0.884 (0.870 to 0.899), other chest discomfort 0.915 (0.897 to 0.934)). Conclusions In a no-treat/treat threshold model, the diagnosis of obstructive CAD using coronary CTA in patients with stable chest pain was most accurate when the clinical pretest probability was between 7% and 67%. Performance of CTA was not influenced by the angina pectoris type and was slightly higher in men and lower in older patients. Systematic review registration PROSPERO CRD42012002780.

Validation of European Society of Cardiology pre-test probabilities for obstructive coronary artery disease in suspected stable angina

“…5 , 12 A recent meta-analysis based on Diamond and Forrester pre-test probabilities demonstrated CTCA to be most accurate in patients with a pre-test probability between 7% and 67%. 18 A specific threshold is not stated in the latest guidelines but applying a 50% threshold to the current pre-test probabilities would infer that nearly all patients should have CTCA where possible. The recommendation for functional testing in patients with >50% pre-test probability is largely based on the recognized potential for discordance between anatomical stenosis severity and the haemodynamic effects of a lesion.…”

Third generation dual source CT with ultra-high pitch protocol for TAVI planning and coronary tree assessment: feasibility, image quality and diagnostic performance

“…Computed tomography (CT) is part of the routine TAVI planning for sizing the valve prosthesis and assessment of the access route [7]. Moreover, CT is used to rule out significant coronary stenosis with low to intermediate pre-test probability for coronary artery disease (CAD) [8]. A holistic CT evaluation of aorta, peripheral vessels and coronary arteries pre-TAVI procedure could lead to a reduction of unnecessary ICA and, consequently, of cumulative radiation dose, contrast volume and risk management.…”

Noninvasive Testing for Diagnosis of Stable Coronary Artery Disease in the Elderly

“…Few studies using coronary CTA for diagnosis of stable CAD in the elderly exist in the literature [ 50 , 51 , 52 , 53 , 54 ]. A meta-analysis of 5332 patients, including 462 patients aged >75 years, reported a sensitivity of coronary CTA for diagnostic of obstructive CAD of 94% and a specificity of 77%, alongside a PPV of 83%, NPV of 91%, LR+ of 4.1 and LR− of 0.08 [ 54 ]. The authors revealed reduced efficacy of coronary CTA for the diagnosis of obstructive coronary atherosclerosis in patients aged >75 years compared to other age groups.…”

“…A meta-analysis of 18 studies reported a sensitivity of 98%, a specificity of 82%, a PPV of 91% and an NPV of 99% [ 59 ]. Another meta-analysis including 65 studies reported a CTA sensitivity of 95% and a specificity of 79% [ 54 ]. The efficacy of CTA in CAD diagnostics was not dependent on the type of chest pain.…”