Umbrella review and multivariate meta-analysis of diagnostic test accuracy studies on hybrid non-invasive imaging for coronary artery disease

Abstract

Background. The diagnosis of coronary artery disease (CAD) remains challenging. It is uncertain whether hybrid imaging can improve diagnostic accuracy for CAD. Methods. This is a systematic review and multivariate meta-analysis. We searched PubMed and The Cochrane Library for recent (‡ 2010) systematic reviews of diagnostic test accuracy studies on non-invasive imaging for CAD. Study-level data were extracted from them, and pooled with pairwise and multivariate meta-analytic methods, using invasive coronary angiography (ICA) or invasive fractional flow reserve (FFR) as reference standards, focusing on sensitivity and specificity. Results. Details from 661 original studies (71,823 patients) were pooled. Pairwise metaanalysis using ICA as reference showed that anatomic imaging was associated with the best diagnostic accuracy (sensitivity = 0.95 [95% confidence interval 0.94-0.96], specificity = 0.83 [0.81-0.85]), whereas using FFR as reference identified hybrid imaging as the best test (sensitivity = 0.87 [0.83-0.90], specificity = 0.82 [0.76-0.87]). Multivariate meta-analysis confirmed the superiority of anatomic imaging using ICA as reference (sensitivity = 0.96, specificity = 0.83), and hybrid imaging using FFR as reference (sensitivity = 0.88 [0.86-0.91], specificity = 0.82 [0.77-0.87]). Conclusions. Non-invasive hybrid imaging tests appear superior to anatomic or functional only tests to diagnose ischemia-provoking coronary lesions, whereas anatomic imaging is best to Electronic supplementary material The online version of this article (

Promises and pitfalls of relying on angiography-derived indexes to identify myocardial ischemia: A tale of Romulus and Remus

“…This argument, which may apply similarly to TCG as well as CT-FFR, is not aimed at debasing CCTA-derived indexes of functional significance of CAD, but rather at highlighting the importance to see each index and parameter as complementary to another. 15,16 Indeed, we firmly believe that modern cardiovascular practice should aim for default hybrid imaging with CCTA and stress only MPI with CZT cameras (Figure 1). Such imaging strategy would yield a veritable mine of anatomic and functional details, overall and at the subvessel and myocardial regional level, ranging from calcium score to plaque characterization, stenosis area and percentage, stress and rest perfusion, necrosis, stunning, hibernation, and functional assessment (including dyssynchrony but possibly also, by means of dual-isotope or repeat imaging, dysinnervation and denervation).…”

Myocardial perfusion imaging with cadmium–zinc–telluride cameras: Harry Potter and the Radiation Hallows?

“…Ongoing developments in the diagnosis and management of ischemic heart disease require a global reappraisal of practitioners, approach to non-invasive imaging tools, ranging from myocardial perfusion imaging (MPI) to computed tomography angiography (CTA) and cardiac magnetic resonance (CMR). [1][2][3] Notwithstanding the need to focus on an integrative approach based on hybrid imaging, capitalizing on the synergy between functional and anatomic imaging tests, it is important to reconsider a time-tested yet elusive concept, which has many important direct and indirect implications for cardiovascular imaging specialists and practitioners: hormesis. 4 This term, deriving from the Ancient Greek ''to set in motion,'' refers to a biological process characterized by an altogether different pathophysiologic dose-response effect, such as low-dose exposure is associated with benefits in comparison to no exposure, whereas high-dose effects are clearly detrimental, notwithstanding the fact that there is no exposure threshold associated with absence of risk.…”

“…10 Accordingly, appropriately selective use of non-invasive imaging tests (e.g., CTA, CMR, and/or MPI), including their smart integration in a logic of hybrid imaging, may improve patient outlook and reduce risk in comparison to the baseline, thanks to favorable diagnostic and prognostic accuracy, as well as improved decisionmaking and elucidation of warranty period. 1,11 Indeed, nuclear medicine in general and nuclear cardiology in particular capitalizes more on the hormesis concept as radiation exposure is not concentrated in a few seconds or minutes, and thus, cellular repairing mechanisms are more capable of adapting appropriately to the corresponding radiologic risk. 6 This framework is also reinforced by an intuitive application of population attributable risk: as IHD is much more prevalent than radiation-induced cancer, the benefits of clinically appropriate imaging testing with limited radiation exposure clearly outweigh the drawbacks.…”

Myocardial-coronary fusion imaging with positron emission tomography and computed tomography: Benchmarking and slingshotting

“…1,3 Most importantly, hybrid imaging offers expanding opportunities to improve patient clustering and treatment, given that integrating details can also be obtained with single or multimodality imaging on myocardial metabolism (important to distinguish between viability and necrosis), systolic function (key to distinguish stunning from hibernation over time), diastolic function, ventricular geometry (to disentangle the impact of CAD on heart failure from heart failure progression per se), and dyssynchronization, as well as innervation/dysinnervation. 1,4 Notably, hybrid imaging appears ''beneficial irrespective of its core components,'' which may include, on top of computed tomography angiography (CTA), any of the latter alone or in combination: stress echocardiography, single-photon emission-computed tomography (SPECT) with myocardial perfusion imaging (MPI), positron emission tomography (PET) with MPI, cardiac magnetic resonance (CMR), computed tomography myocardial perfusion (CTP), and computed tomography fractional flow reserve (CTFFR), PET, and SPECT with assessment of coronary flow reserve (CFR). 2 Accordingly, institutional and operator expertise, with the complex interplay between training, skill, and volume, may impact on the choice and performance of each component of hybrid imaging.…”

“…2 In addition, anatomic, functional, and hybrid assessment cannot disregard the ongoing quest for appropriate definition of the strengths and weaknesses of qualitative, semiquantitative, and quantitative assessment of imaging results. 4 Finally, while PET has several unique features, it is expensive and its use in routine cardiovascular practice still a niche one. 3 Given its wider availability and efficiency, SPECT continues to play an important role in functional imaging as well as in hybrid imaging.…”