Diagnostic accuracy and clinical utility of noninvasive testing for coronary artery disease.
BACKGROUND
Computed tomography coronary angiography (CTCA) has become a popular noninvasive test for diagnosing coronary artery disease.


OBJECTIVE
To compare the accuracy and clinical utility of stress testing and CTCA for identifying patients who require invasive coronary angiography (ICA).


METHODS
Observational study.


METHODS
University medical center in Rotterdam, the Netherlands.


METHODS
517 patients referred by their treating physicians for evaluation of chest symptoms by using stress testing or ICA.


METHODS
Stress testing and CTCA in all patients.


METHODS
Diagnostic accuracy of stress testing and CTCA compared with ICA; pretest probabilities of disease by Duke clinical score; and clinical utility of noninvasive testing, defined as a pretest or posttest probability that suggests how to proceed with testing (no further testing if < or =5%, proceed with ICA if between 5% and 90%, and refer directly for ICA if > or =90%).


RESULTS
Stress testing was not as accurate as CTCA; CTCA sensitivity approached 100%. In patients with a low (<20%) pretest probability of disease, negative stress test or CTCA results suggested no need for ICA. In patients with an intermediate (20% to 80%) pretest probability, a positive CTCA result suggested need to proceed with ICA (posttest probability, 93% [95% CI, 92% to 93%]) and a negative result suggested no need for further testing (posttest probability, 1% [CI, 1% to 1%]). Physicians could proceed directly with ICA in patients with a high (>80%) pretest probability (91% [CI, 90% to 92%]).


CONCLUSIONS
Referral and verification bias might have influenced findings. Stress testing provides functional information that may add value to that from anatomical (CTCA or ICA) imaging.


CONCLUSIONS
Computed tomography coronary angiography seems most valuable in patients with intermediate pretest probability of disease, because the test can distinguish which of these patients need invasive angiography. These findings need to be confirmed before CTCA can be routinely recommended for these patients.
Weustink
Annick C
AC
Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
Mollet
Nico R
NR
Neefjes
Lisan A
LA
Meijboom
W Bob
WB
Galema
Tjebbe W
TW
van Mieghem
Carlos A
CA
Kyrzopoulous
Stamatis
S
Eu
Rick Neoh
RN
Nieman
Koen
K
Cademartiri
Filippo
F
van Geuns
Robert-Jan
RJ
Boersma
Eric
E
Krestin
Gabriel P
GP
de Feyter
Pim J
PJ
D017023:Coronary Angiography / Q000379:methods; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000000981:diagnostic imaging; D004562:Electrocardiography; D005080:Exercise Test / Q000379:methods; D006801:Humans; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015899:Tomography, Emission-Computed, Single-Photon; D014057:Tomography, X-Ray Computed