Stress testing and non-invasive coronary angiography in patients with suspected coronary artery disease: time for a new paradigm

Abstract

Diagnosis and management of coronary artery disease represents major challenges to our health care system, affecting millions of patients each year. Until recently, the diagnosis of coronary artery disease was possible only through cardiac catheterization and invasive coronary angiography. To avoid the risks of an invasive procedure, stress testing is often employed for an initial assessment of patients with suspected coronary artery disease, serving as a gatekeeper for cardiac catheterization. With the emergence of non-invasive coronary angiography, the question arises if such a strategy is still sensible, particularly, in view of only a modest agreement between stress testing results and the presence of coronary artery disease established by cardiac catheterization. Much data in support of the diagnostic accuracy and prognostic value of non-invasive coronary angiography by computed tomography have emerged within the last few years. These data challenge the role of stress testing as the initial imaging modality in patients with suspected coronary artery disease. This article reviews the clinical utility, limitations, as well as the hazards of stress testing compared with non-invasive coronary artery imaging by computed tomography. Finally, the implications of this review are discussed in relation to clinical practice.

Keywords: CT angiography; cardiac CT; coronary artery disease.; stress testing.

Figure 1

Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of computed tomography angiography for detecting 50% stenosis or over by quantitative coronary angiography based on a meta-analysis of 3,674 symptomatic patients without history of coronary artery disease enrolled in 28 studies.

Figure 2

Annualized rates of death or myocardial infarction after computed tomography angiography according to study results based on a meta-analysis of 9,592 patients enrolled in 18 studies. CAD, coronary artery disease.

Figure 3

Schema for a proposed algorithm of triaging patients with suspected but without known coronary artery disease. CAD, coronary artery disease; CTA, computed tomography angiography; tx, therapy.