1. In this meta-analysis of randomized clinical trials, coronary computed tomography angiography (CCTA) compared to functional stress testing was associated with no difference in mortality or cardiac hospitalization compared to functional stress testing.
2. Patients undergoing CCTA were more likely to undergo invasive coronary angiography, revascularization, initiate statin and aspirin therapy, and have a statistically significant, yet likely clinically insignificant, incidence of myocardial infarction.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Coronary computed tomography angiography (CCTA) allows for the rapid evaluation of patients with suspected coronary artery disease to undergo evaluation for anatomic lesions and offers improved diagnostic accuracy compared to functional testing. The impact of CCTA on clinical outcomes has been evaluated in prior studies with differing conclusions. The current study is a meta-analysis of all available randomized trials comparing CCTA to functional stress testing with regards to clinical outcomes of patients with suspected acute or stable coronary artery disease. The study found that patients who underwent CCTA were more likely to get started on aspirin and statin medications, undergo invasive coronary angiography, and revascularization. They also had a statistically significant reduction in rate of myocardial infarction, yet the difference is likely clinically insignificant. There was no observed difference in mortality or hospitalization for cardiac indications between the two strategies.
The current study offers some insight into the clinical characteristics of CCTA testing. The main strengths of this study is its inclusion of a large number of included patients and evaluation of populations for suspected stable and acute coronary syndromes. The main limitations of the study include the reliance on trial level data prohibiting the evaluation of important. Finally, the comparison groups included a wide variety of functional stress testing and may not offer a consistent contrast.
Click to read the study, published in JAMA Internal Medicine
Relevant Reading: Prognostic assessment of stable coronary artery disease as determined by coronary computed tomography angiography: a Danish multicentre cohort study
In-Depth [systematic review and meta-analysis]: This study included all randomized controlled trials (RCTs) from 2000 to 2016 that compared CCTA to functional stress testing in patients with suspected coronary artery disease. Studies were included if they had at least 1 month of follow-up, included data on clinical outcomes, and patient management. Observational studies and studies without comparison to functional stress testing were no included.
The analysis included 20 092 patients from 13 RCTs with a median of 18 months of follow up. There was no observed difference in mortality or cardiac hospitalization between CCTA and functional stress testing. Rate of MI was lower for the CCTA group (0.7% vs 1.1%; RR, 0.71; 95%CI, 0.53-0.96), while rates of 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) were higher. Patients undergoing CCTA were also more likely to have a new diagnosis of coronary artery disease, and initiate aspirin and statin therapy.
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