Coronary Computed Tomography Angiography vs Functional Stress Testing for Patients With Suspected Coronary Artery Disease: A Systematic Review and Meta-analysis

Abstract

Importance: Coronary computed tomography angiography (CCTA) is a new approach for the diagnosis of anatomical coronary artery disease (CAD), but it is unclear how CCTA performs compared with the standard approach of functional stress testing.

Objective: To compare the clinical effectiveness of CCTA with that of functional stress testing for patients with suspected CAD.

Data sources: A systematic literature search was conducted in PubMed and MEDLINE for English-language randomized clinical trials of CCTA published from January 1, 2000, to July 10, 2016.

Study selection: Researchers selected randomized clinical trials that compared a primary strategy of CCTA with that of functional stress testing for patients with suspected CAD and reported data on patient clinical events and changes in therapy.

Data extraction and synthesis: Two reviewers independently extracted data from and assessed the quality of the trials. This analysis followed the PRISMA statement for reporting systematic reviews and meta-analyses and used the Cochrane Collaboration's tool for assessing risk of bias in randomized trials. The Mantel-Haenszel method was used to conduct the primary analysis. Summary relative risks were calculated with a random-effects model.

Main outcomes and measures: The outcomes of interest were all-cause mortality, cardiac hospitalization, myocardial infarction, invasive coronary angiography, coronary revascularization, new CAD diagnoses, and change in prescription for aspirin and statins.

Results: Thirteen trials were included, with 10 315 patients in the CCTA arm and 9777 patients in the functional stress testing arm who were followed up for a mean duration of 18 months. There were no statistically significant differences between CCTA and functional stress testing in death (1.0% vs 1.1%; risk ratio [RR], 0.93; 95% CI, 0.71-1.21) or cardiac hospitalization (2.7% vs 2.7%; RR, 0.98; 95% CI, 0.79-1.21), but CCTA was associated with a reduction in the incidence of myocardial infarction (0.7% vs 1.1%; RR, 0.71; 95% CI, 0.53-0.96). Patients undergoing CCTA were significantly more likely to undergo invasive coronary angiography (11.7% vs 9.1%; RR, 1.33; 95% CI, 1.12-1.59) and revascularization (7.2% vs 4.5%; RR, 1.86; 95% CI, 1.43-2.43). They were also more likely to receive a diagnosis of new CAD and to have initiated aspirin or statin therapy.

Conclusions and relevance: Compared with functional stress testing, CCTA is associated with a reduced incidence of myocardial infarction but an increased incidence of invasive coronary angiography, revascularization, CAD diagnoses, and new prescriptions for aspirin and statins. Despite these differences, CCTA is not associated with a reduction in mortality or cardiac hospitalizations.

Figure 1.. PRISMA Diagram

CCTA indicates coronary computed tomography angiography; RCT, randomized clinical trial; and SC, standard care (stress testing in all or most patients in the control group).

Figure 2.. Forest Plot for Myocardial Infarction

Risk ratios (RRs) were determined by the Mantel-Haenszel method with a random-effects model. Square data markers represent RRs; horizontal lines, the 95% CIs with marker size reflecting the statistical weight of the study using random-effects meta-analysis. A diamond data marker represents the overall RR and 95% CI for the outcome of interest. ACRIN/PA indicates American College of Radiology Imaging Network/Pennsylvania Department of Health; CAPP, Cardiac CT for the Assessment of Pain and Plaque; CATCH, Cardiac CT in the Treatment of Acute Chest pain; CCTA, coronary computed tomography angiography; CT-COMPARE, CT Coronary Angiography Compared to Exercise ECG; CT-STAT, Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patient to Treatment; PERFECT, Prospective First Evaluation in Chest Pain; PROMISE, Prospective Multicenter Imaging Study for Evaluation of Chest Pain; PROSPECT, Prospective Randomized Outcome Trial Comparing Radionuclide Stress Myocardial Perfusion Imaging and ECG-Gated Coronary CT Angiography; ROMICAT-II, Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography–II; and SCOT-HEART, Scottish Computed Tomography of the Heart Trial.

Figure 3.. Forest Plot for Revascularization

Risk ratios (RRs) were determined by the Mantel-Haenszel method with a random-effects model. Square data markers represent RRs; horizontal lines, the 95% CIs with marker size reflecting the statistical weight of the study using random-effects meta-analysis. A diamond data marker represents the overall RR and 95% CI for the outcome of interest. ACRIN/PA indicates American College of Radiology Imaging Network/Pennsylvania Department of Health; CAPP, Cardiac CT for the Assessment of Pain and Plaque; CATCH, Cardiac CT in the Treatment of Acute Chest pain; CCTA, coronary computed tomography angiography; CT-COMPARE, CT Coronary Angiography Compared to Exercise ECG; CT-STAT, Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patient to Treatment; PERFECT, Prospective First Evaluation in Chest Pain; PROMISE, Prospective Multicenter Imaging Study for Evaluation of Chest Pain; PROSPECT, Prospective Randomized Outcome Trial Comparing Radionuclide Stress Myocardial Perfusion Imaging and ECG-Gated Coronary CT Angiography; ROMICAT-II, Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography–II; and SCOT-HEART, Scottish Computed Tomography of the Heart Trial.