Comparison of mid- to long-term clinical outcomes between anatomical testing and usual care in patients with suspected coronary artery disease: A meta-analysis of randomized trials

Abstract

Background: Controversies remain regarding clinical outcomes following initial strategies of coronary computed tomography angiography (CCTA) vs usual care with functional testing in patients with suspected coronary artery disease (CAD).

Hypothesis: CCTA as initial diagnostic strategy results in better mid- to long-term outcomes than usual care in patients with suspected CAD.

Methods: We searched PubMed, Embase, and Cochrane Library for randomized controlled trials comparing clinical outcomes during ≥6 months' follow-up between initial anatomical testing by CCTA vs usual care with functional testing in patients with suspected CAD. Occurrence of all-cause mortality, nonfatal myocardial infarction (MI), and major adverse cardiovascular events (MACE), and use of invasive coronary angiography and coronary revascularization, were compared between the 2 diagnostic strategies.

Results: Twelve trials were included (20 014 patients; mean follow-up, 20.5 months). Patients undergoing CCTA as initial noninvasive testing had lower risk of nonfatal MI compared with those treated with usual care (risk ratio [RR]: 0.70, 95% confidence interval [CI]: 0.52-0.94, P = 0.02). There was a tendency for reduced MACE following initial CCTA strategy, but not for risk of all-cause mortality. Compared with functional testing, the CCTA strategy increased use of invasive coronary angiography (RR: 1.53, 95% CI: 1.12-2.09, P = 0.007) and coronary revascularization (RR: 1.49, 95% CI: 1.11-2.00, P = 0.007).

Conclusions: Anatomical testing with CCTA as the initial noninvasive diagnostic modality in patients with suspected CAD resulted in lower risk of nonfatal MI than usual care with functional testing, at the expense of more frequent use of invasive procedures.

Keywords: Anatomical Testing; Coronary Artery Disease; Coronary CT Angiography; Functional Testing; Meta-Analysis.

Figure 1

Flow diagram of study selection. Abbreviations: RCT, randomized controlled trial

Figure 2

Clinical outcomes following initial anatomical vs functional testing for (A) nonfatal MI, (B) MACE, and (C) all‐cause mortality. Abbreviations: ACRIN‐PA, American College of Radiology Imaging Network–Pennsylvania; CAPP, Cardiac CT for the Assessment of Pain and Plaque; CATCH, Cardiac CT in the Treatment of Acute Chest Pain; CI, confidence interval; df, degrees of freedom; CCTA, coronary computed tomography angiography; CRESCENT, Computed Tomography vs Exercise Testing in Suspected Coronary Artery Disease; CT‐COMPARE, CT Coronary Angiography to Measure Plaque Reduction; CT‐STAT, Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment; IAEA‐SPECT/CTA, Functional compared to anatomical imaging in the initial evaluation of patients with suspected coronary artery disease; MACE, major adverse cardiac events; M‐H, Mantel–Haenszel; MI, myocardial infarction; 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 CCTA; SCOT‐HEART, Scottish Computed Tomography of the HEART

Figure 3

Comparison of CV events in studies with follow‐up duration ≥12 months for (A) all‐cause mortality, (B) nonfatal MI, and (C) MACE. Abbreviations: ACRIN‐PA, American College of Radiology Imaging Network–Pennsylvania; CAPP, Cardiac CT for the Assessment of Pain and Plaque; CATCH, Cardiac CT in the Treatment of Acute Chest Pain; CI, confidence interval; df, degrees of freedom; CCTA, coronary computed tomography angiography; CRESCENT, Computed Tomography vs Exercise Testing in Suspected Coronary Artery Disease; CT‐COMPARE, CT Coronary Angiography to Measure Plaque Reduction; CV, cardiovascular; MACE, major adverse cardiac events; M‐H, Mantel–Haenszel; MI, myocardial infarction; 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 CCTA; SCOT‐HEART, Scottish Computed Tomography of the HEART

Figure 4

Use of invasive procedures following initial anatomical vs functional testing for (A) ICA and (B) coronary revascularization. Abbreviations: ACRIN‐PA, American College of Radiology Imaging Network–Pennsylvania; CAPP, Cardiac CT for the Assessment of Pain and Plaque; CATCH, Cardiac CT in the Treatment of Acute Chest Pain; CI, confidence interval; df, degrees of freedom; CCTA, coronary computed tomography angiography; CRESCENT, Computed Tomography vs Exercise Testing in Suspected Coronary Artery Disease; CT‐COMPARE, CT Coronary Angiography to Measure Plaque Reduction; CT‐STAT, Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment; ICA, invasive coronary angiography; IAEA‐SPECT/CTA, Functional compared to anatomical imaging in the initial evaluation of patients with suspected coronary artery disease; M‐H, Mantel–Haenszel; 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 CCTA; SCOT‐HEART, Scottish Computed Tomography of the HEART