Is a coronary computed tomography angiography (CTA) a suitable initial diagnostic test for a 50-year-old male patient with hypertension and hyperlipidemia presenting with chest discomfort and possible ischemia in the inferior lateral wall?

Coronary CTA for Evaluation of Suspected Coronary Artery Disease

Coronary computed tomography angiography (CCTA) is recommended as the appropriate next diagnostic test for this 50-year-old male patient with hypertension, hyperlipidemia, chest discomfort, and possible ischemia in the inferior lateral wall. 1, 2

Rationale for Coronary CTA

• CCTA is recommended by the European Society of Cardiology (ESC) as a first-line test for patients with suspected coronary artery disease (CAD) when the pre-test likelihood is >5% 1
• For patients with low to moderate (15-50%) pre-test likelihood of obstructive CAD, CCTA is particularly valuable due to its high negative predictive value (>95%) 2
• This patient's risk factors (age 50, male, hypertension, hyperlipidemia) and symptoms (chest discomfort with possible ischemia) place him in a category where CCTA would be appropriate 1, 2

Advantages of CCTA in This Clinical Scenario

• CCTA provides direct visualization of coronary anatomy with excellent sensitivity (95-99%) for detecting obstructive CAD 1
• CCTA can detect both obstructive and non-obstructive coronary disease, which is particularly important in patients with hypertension who have higher prevalence and severity of CAD 3
• CCTA allows assessment of plaque composition and high-risk plaque features that may be relevant in risk stratification 2
• When compared to conventional ischemia testing, CCTA has been shown to reduce downstream diagnostic test utilization 4

Management Algorithm Based on CCTA Findings

1. If CCTA shows no CAD: This effectively rules out obstructive disease (negative predictive value approaching 100%) 1
2. If CCTA shows non-obstructive CAD: Consider intensified preventive measures 2
3. If CCTA shows intermediate stenosis (50-69%): Consider functional assessment with CT-derived fractional flow reserve (CT-FFR) or additional stress testing 2
4. If CCTA shows severe stenosis (≥70%): Consider referral for invasive coronary angiography 2

Important Considerations and Limitations

• CCTA is not recommended when extensive coronary calcification, irregular heart rate, significant obesity, or inability to cooperate with breath-hold commands makes good image quality unlikely 1
• If CCTA shows CAD of uncertain functional significance or is not diagnostic, functional imaging for myocardial ischemia is recommended as the next step 1
• The ESC guidelines specifically state that functional imaging is recommended if CCTA has shown CAD of uncertain functional significance 1

Evidence Supporting CCTA in This Patient Population

• The 2024 ESC guidelines for chronic coronary syndromes strongly recommend CCTA as an initial diagnostic test in patients with suspected CAD 1
• Studies have shown that patients with hypertension have more prevalent and severe CAD compared to normotensive patients, making detailed anatomical assessment valuable 3
• Early coronary CTA in patients with chest pain has been shown to significantly improve patient management 5
• The ROMICAT trial demonstrated that coronary CTA has excellent sensitivity and negative predictive value for acute coronary syndrome in patients presenting with chest pain 5

In conclusion, given this patient's clinical profile with hypertension, hyperlipidemia, chest discomfort, and possible ischemia, coronary CTA represents the most appropriate next diagnostic step to evaluate for coronary artery disease.