The effectiveness of coronary computed tomography angiography and functional testing for the diagnosis of obstructive coronary artery disease: results from the individual patient data Collaborative Meta-Analysis of Cardiac CT (COME-CCT)
Authors: Schlattmann Peter , Wieske Viktoria , Bressem Keno K. , Götz Theresa , Schuetz Georg M. , Andreini Daniele , Pontone Gianluca , Alkadhi Hatem , Hausleiter Jörg , Zimmermann Elke , Gerber Bernhard , Shabestari Abbas A. , Meijs Matthijs F. L. , Sato Akira , Øvrehus Kristian A. , Jenkins Shona M. M. , Knuuti Juhani , Hamdan Ashraf , Halvorsen Bjørn A. , Mendoza-Rodriguez Vladimir , Rixe Johannes , Wan Yung-Liang , Langer Christoph , Leschka Sebastian , Martuscelli Eugenio , Ghostine Said , Tardif Jean-Claude , Sánchez Alejandra Rodríguez , Haase Robert , Dewey Marc 
Published: August 2024

Abstract
Aim
To determine the effectiveness of functional stress testing and computed tomography angiography (CTA) for diagnosis of obstructive coronary artery disease (CAD).

Methods and results
Two-thousand nine-hundred twenty symptomatic stable chest pain patients were included in the international Collaborative Meta-Analysis of Cardiac CT consortium to compare CTA with exercise electrocardiography (exercise-ECG) and single-photon emission computed tomography (SPECT) for diagnosis of CAD defined as ≥ 50% diameter stenosis by invasive coronary angiography (ICA) as reference standard. Generalised linear mixed models were used for calculating the diagnostic accuracy of each diagnostic test including non-diagnostic results as dependent variables in a logistic regression model with random intercepts and slopes. Covariates were the reference standard ICA, the type of diagnostic method, and their interactions. CTA showed significantly better diagnostic performance (p < 0.0001) with a sensitivity of 94.6% (95% CI 92.7–96) and a specificity of 76.3% (72.2–80) compared to exercise-ECG with 54.9% (47.9–61.7) and 60.9% (53.4–66.3), SPECT with 72.9% (65–79.6) and 44.9% (36.8–53.4), respectively. The positive predictive value of CTA was ≥ 50% in patients with a clinical pretest probability of 10% or more while this was the case for ECG and SPECT at pretest probabilities of ≥ 40 and 28%. CTA reliably excluded obstructive CAD with a post-test probability of below 15% in patients with a pretest probability of up to 74%.

Conclusion
In patients with stable chest pain, CTA is more effective than functional testing for the diagnosis as well as for reliable exclusion of obstructive CAD. CTA should become widely adopted in patients with intermediate pretest probability.

Systematic review registration
PROSPERO Database for Systematic Reviews—CRD42012002780.

Critical relevance statement
In symptomatic stable chest pain patients, coronary CTA is more effective than functional testing for diagnosis and reliable exclusion of obstructive CAD in intermediate pretest probability of CAD.

Key Points

Coronary computed tomography angiography showed significantly better diagnostic performance (p < 0.0001) for diagnosis of coronary artery disease compared to exercise-ECG and SPECT.

The positive predictive value of coronary computed tomography angiography was ≥ 50% in patients with a clinical pretest probability of at least 10%, for ECG ≥ 40%, and for SPECT 28%.

Coronary computed tomography angiography reliably excluded obstructive coronary artery disease with a post-test probability of below 15% in patients with a pretest probability of up to 74%.

Graphical Abstract