Coronary CTA Should Be the Initial Test in Most Patients With Stable Chest Pain: CON

Editor's Note: This is the Con article of a two-part Pro/Con Expert Analysis. Click here for the Pro article.

Appropriate risk stratification of patients presenting with stable chest pain is crucial not only for the individual but also for health care systems across the world. Despite the development of several well-established clinical pathways, it is difficult to define a singular approach applicable to all patients due to heterogeneity of clinical presentations and comorbid conditions. In fact, some of the current approaches seem to have significant limitations, as evidenced by the low prevalence of obstructive coronary artery disease (CAD) found on invasive coronary angiography (ICA) even after noninvasive testing.1,2 Yet, the future is promising given recent advances in testing modalities including coronary computed tomography angiography (CTA). Coronary CTA has experienced a sharp rise in development over recent years based on robust data demonstrating its diagnostic and prognostic utility in the detection of CAD. However, although coronary CTA may be a suitable test in some patients, it is not the appropriate initial test for most patients with stable chest pain.

Coronary CTA certainly has excellent sensitivity to detect underlying CAD. Several cohort studies and randomized clinical trials have studied the diagnostic accuracy of coronary CTA with respect to ICA. For example, the ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial studying 230 patients and a pooled analysis report by the European Society of Cardiology and European Council of Nuclear Cardiology studying 800 patients reported a sensitivity of 94% and 89% for a stenosis ≥70% and ≥50%, respectively.3,4 These findings are generally representative of several other cohort data. Furthermore, a meta-analysis of 16 studies including 1,119 patients found a sensitivity of 96% to detect significant coronary stenoses in the setting of stable ischemic heart disease.5 Despite the high correlation of coronary CTA and ICA, these comparisons provide only anatomic correlation and do not address the physiologic significance of coronary disease nor provide an estimation of the ischemic burden, a key component of outcome and therapeutic planning.

The sensitivity to detect anatomic CAD should not be the sole basis upon which to decide the appropriateness of an initial test for stable chest pain. The ideal initial test should be practical, generalizable, and safe while also demonstrating an ability to diagnose significant CAD, define prognosis, and plot a course of treatment. In fact, the appropriate evaluation for most patients is simply a comprehensive clinical assessment with determination of the pre-test probability of CAD. The Diamond-Forrester Criteria and the two CAD consortium scores can effectively risk stratify patients while both avoiding unnecessary testing in up to 1/3 of patients and identifying those who should proceed directly to ICA.6,7 Multiple studies have found that even the most recent models overestimate the pre-test likelihood of CAD given that approximately 60% of elective ICAs found no obstructive CAD.1,8 Optimal pre-test prediction models are actively being investigated to assist in refining our clinical acumen.1,8 The PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) minimal risk tool can result in avoidance of noninvasive testing in over 25% of patients with no difference in outcomes (Table 1).9 In addition, PROMISE demonstrated that coronary CTA also increased the rate of ICA by almost 50% compared with routine provocative testing.9,10 Several meta-analyses have confirmed that coronary CTA increases downstream ICA and revascularization rates with a small decrease in myocardial infarction but of unclear etiology and significance, thus underscoring the need for improved management strategies after coronary CTA results.11,12 Thus, coronary CTA may result in unnecessary ICA and subsequent intervention without improvement in mortality.

Table 1: Components of PROMISE Minimal Risk Tool



Racial/Ethnic Minority

Ever Smoked Tobacco



Family History of Premature CAD


Symptoms Related to Physical/Mental Stress

High-Density Lipoprotein Value (mg/dL)

When clinical assessment is inadequate, noninvasive testing should be considered. Several options are available depending on specific patient factors, such as exercise capacity, electrocardiogram (ECG) interpretability, and known cardiac disease. Although coronary CTA is not dependent on exercise or ECG interpretability, this technique is limited by its inability to provide physiologic information. Therefore, in the United States, exercise stress electrocardiography (graded exercise testing [GXT]) remains the recommended initial diagnostic test for patients with low to intermediate pre-test probability of CAD with an interpretable ECG and who are able to exercise maximally.13,14 GXT has a substantial ability to predict future cardiac events, and more technologically advanced diagnostic tools have not yet been able to supplant the prognostic power of exercise.15,16

Coronary CTA does not routinely involve a physiologic assessment and, therefore, does not address the ischemic cascade like other provocative modalities.17 Coronary CTA also does not yield a key prognostic variable: the presence and extent of inducible myocardial ischemia. Decades of data from noninvasive trials have revealed that ischemic burden is a key predictor of cardiac-event-free survival and helps to stratify patients and plan therapeutic interventions.18-22 More recently, the invasive assessment of coronary physiology through fractional flow reserve and instantaneous wave-free ratio determinations has been shown to identify hemodynamically significant stenoses, assist in planning revascularization to improve cardiovascular outcomes, and avoid unnecessary interventional procedures.23-26 Because physiology-guided revascularization results in improved cardiovascular outcomes compared with angiography-guided revascularization, the next step in coronary CTA evaluation seems to involve the determination of fractional flow reserve by computed tomography (FFRCT). FFRCT has been shown to alter management in over 1/3 of patients and reduce the need for ICA in patients without obstructive disease.27,28 Interestingly, several of these management changes involved stenoses at the extremes; 30% of vessels with >90% stenosis were surprisingly found to be functionally insignificant, and 10% of stenoses <50% were actually found to be significant.27

Despite the promise of coronary CTA (with and without FFRCT), technique and patient-related limitations exist for the widespread application of this technology. Multiple patient-specific factors may result in suboptimal images, including a body mass index greater than 40 kg/m2, frequent ectopy, atrial fibrillation, tachycardia, and an inability to receive beta-blockers or nitroglycerin.29,30 Additionally, patients with renal insufficiency or an allergy to contrast agents are unable to undergo coronary CTA. Interpretation of images, even in expert centers, is difficult in the presence of coronary stents, small vessels <2 mm, severe calcification, and bypass grafts in relation to their insertion points.29 The aforementioned limitations may therefore exclude over 1/3 of patients and/or can result in non-diagnostic studies.29,31 Furthermore, the excellent diagnostic results have been reported only from highly skilled centers, raising the question of how this will translate to institutions with less-experienced readers and protocol managers.32-34 The availability of at least 64-slice scanners remains limited, and the negative effects of radiation are still considerations despite improved technology.29,35,36 Finally, extracardiac incidental findings such as pulmonary nodules may be found in up to 1/3 of cases, and although such secondary findings may not confer a profound change in a patient's prognosis, they can affect mental stress and lead to further testing and a potential increase health care costs.10,37

An alternative to the use of coronary CTA in the setting of stable chest pain may be with the use of coronary artery calcium scoring (CACS) because this appears to have adequate value as an initial test after clinical assessment in the intermediate risk population. CACS determination is a rapid test and does not require contrast or an intricate protocol. CACS has demonstrated reclassification rates of over 50% when added to clinical and exercise variables with cutoffs that are well-validated for event-free survival.38 Moreover, coronary CTA may not provide incremental risk stratification when compared with CACS alone.39 Additionally, coronary CTA appears unable to exclude high-grade CAD when the Agatston score is >287 and does not add value if the Agatston score is zero, essentially representing an extremely low likelihood of CAD.40

At the current time, most clinical practice guidelines do not support coronary CTA as the initial test in the majority of patients with stable chest pain. The American College of Cardiology guidelines for stable ischemic heart disease include coronary CTA as an option if there are contraindications to stress testing or for patients who are unable to exercise.13,14 The appropriate use criteria guidelines note that it is "rarely appropriate" to use coronary CTA in low-risk populations that can exercise, thus restricting the use of this method.41 The recently published National Institute for Health and Care Excellence (NICE) guidelines that strongly support coronary CTA as a diagnostic choice for chest pain patients do emphasize clinical assessment first, with coronary CTA recommended only if this clinical stratification suggests underlying CAD.42 However, there is significant concern regarding widespread implementation of the NICE guidelines due to the requirement of a much larger specialist workforce and coronary CTA-capable scanners.43

Although practical issues and a lack of physiologic information limits its widespread use, coronary CTA and its variations can enhance our diagnostic and prognostic abilities for some patients when the presence and severity of CAD remains in doubt. However, when considering the strength of clinical assessment with newer clinical risk models that may eliminate the need for noninvasive testing in several patient populations and the shortcomings of coronary CTA regarding an increased cost with downstream ICA and revascularization without clinical benefit, lack of physiologic data, and patient- and technique-related limitations including high coronary artery calcium, coronary CTA cannot be recommended as an appropriate initial test in many patients presenting with stable chest pain.


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Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging, Hypertension

Keywords: Angina Pectoris, Angina, Unstable, Angiography, Aspirin, Atrial Fibrillation, Body Mass Index, Calcium, Catheterization, Chest Pain, Cohort Studies, Constriction, Pathologic, Coronary Angiography, Coronary Artery Disease, Coronary Stenosis, Critical Pathways, Diabetes Mellitus, Diagnostic Tests, Routine, Disease-Free Survival, Dyslipidemias, Electrocardiography, Exercise Test, Exercise Test, Follow-Up Studies, Health Care Costs, Heart Rate, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypersensitivity, Hypertension, Incidental Findings, Life Style, Lipoproteins, HDL, Myocardial Infarction, Myocardial Perfusion Imaging, National Health Programs, Nitroglycerin, Odds Ratio, Patient Selection, Positron-Emission Tomography, Prevalence, Prognosis, Prospective Studies, Referral and Consultation, Risk Factors, Renal Insufficiency, Cardiac-Gated Single-Photon Emission Computer-Assisted Tomography, Stents, Tachycardia, Tomography, Tomography, Emission-Computed, Single-Photon, Tomography, X-Ray Computed, Vascular Calcification, Diagnostic Imaging

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