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Original Investigation
October 2, 2017

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

Author Affiliations
  • 1Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
  • 2Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
  • 3Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 4Louisville Cardiology Group, Baptist Health, Louisville, Kentucky
  • 5Department of Medicine, University of Maryland School of Medicine, Baltimore
  • 6Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
  • 7Editor, JAMA Internal Medicine
JAMA Intern Med. Published online October 2, 2017. doi:10.1001/jamainternmed.2017.4772
Key Points

Question  For patients with suspected coronary artery disease, what is the effect on clinical outcomes of coronary computed tomography angiography compared with functional stress testing?

Findings  This systematic review and meta-analysis of randomized clinical trials found that, compared with functional stress testing, coronary computed tomography angiography may reduce the incidence of myocardial infarction, but not death or cardiac hospitalizations. Coronary computed tomography angiography increased the downstream rates of invasive coronary angiography and coronary revascularization, as well as new coronary artery disease diagnoses and new prescriptions for aspirin and statin medications.

Meaning  Compared with functional stress testing, coronary computed tomography angiography is associated with a decreased incidence of myocardial infarction in patients with suspected coronary artery disease, as well as an increase in detection of coronary artery disease and use of secondary prevention medications; tradeoffs involve an increase in downstream invasive procedures, many of which may be unnecessary.

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.

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