Coronary computed tomography angiography in primary care patients with chest pain or dyspnea - a cross-sectional study

Abstract

Aims: Coronary Computed Tomography Angiography (CCTA) is recommended as a first-line investigation to exclude significant coronary artery stenosis in case of low to intermediate pre-test probability (PTP). The aim was to investigate CCTA findings in relation to the PTP of patients referred directly from primary health care centres.

Methods/results: In this retrospective cohort study consecutive primary care CCTA referrals in a Swedish county 1st of June 2021 until 30th Nov. 2022 were included. CCTA reports were obtained for 483 patients ≥ 30 years old, without known CAD and stratified as no CAD, with atheromatosis or with suspected significant stenosis. For the 381 patients with eligible PTP data, the mean age was 60 years and 70% were women. While the median PTP was 11%, significant stenosis was suspected on CCTA in 18%. Among patients with PTP ≤ 15%, CCTA exposed no significant stenosis in 88%. No significant stenosis was found in patients with PTP < 5% true to patient age and gender in a sensitivity analysis (n = 25).

Conclusions: CCTA ruled out coronary stenosis as the cause of chest pain and dyspnea in 88% of patients referred from primary care with PTP 5-15%. PTP estimations by primary care physicians in CCTA referrals agreed with the occurrence of suspected significant stenosis among patients with PTP 5-15%, but underestimated it in PTP > 15%. The validity of PTP estimates < 5% was low.

Fig. 1

Flowchart of inclusion, exclusion, and patients eligible for analysis. The study included patients by date of referral to coronary computed tomography angiography (CCTA) from primary health care centres (PHCCs). At study closing 207 patients had not obtained a CCTA in the county, a majority of whom had been referred within 90 days and 81% with pre-test probability (PTP) > 5%

Fig. 2

Coronary computed tomography angiography (CCTA) findings per group of pre-test probability (PTP) estimated by the referring primary care physician. Of the 381 patients with eligible PTP and completed CCTA, two had inconclusive scan results and are not shown in the figure. Bars represent ‘no CAD’ (coronary artery disease, bottom), atheromatosis (middle) and suspected significant stenosis (≥ 50% occlusion, top)

Fig. 3

Subset analysis (n = 315, two inconclusive CCTA with PTP 5–15% not shown) of CCTA findings per group of PTP for patients referred with figures of PTP consistent with gender and age interval in the PTP tables published by the European Society of Cardiology in 2019. PTP figures not consistent with either were excluded post-hoc (n = 66) from the main analysis group (n = 381). Bars represent ‘no CAD’ (coronary artery disease, bottom), atheromatosis (middle) and suspected significant stenosis (≥ 50% occlusion, top)