From the Guidelines
The best test for coronary stenosis is Coronary Computed Tomography Angiography (CCTA), which provides high sensitivity and specificity for detecting coronary artery stenoses. This non-invasive imaging technique is recommended as the preferred diagnostic modality for ruling out obstructive CAD in individuals with low or moderate pre-test likelihood 1. The advantages of CCTA include its high negative predictive value, allowing for safe discharge from the emergency department without further workup, and its ability to provide detailed anatomical information about the coronary arteries 1. Some key points to consider when choosing a diagnostic test for coronary stenosis include:
- The pre-test likelihood of obstructive CAD, with CCTA being recommended for individuals with low or moderate pre-test likelihood 1
- The availability of imaging modalities at the healthcare facility, with CCTA being widely available and cost-effective
- The need for functional imaging for myocardial ischemia, with CCTA being recommended if functional imaging is not diagnostic 1
- The presence of intermediate coronary artery stenosis, with CT-based FFR being considered in these cases 1 Other diagnostic tests, such as stress echocardiography, stress cardiac magnetic resonance, and positron emission tomography, may also be used in certain situations, but CCTA is generally the preferred initial test due to its high sensitivity and specificity 1. Invasive coronary angiography with invasive functional assessments may be recommended to confirm or exclude the diagnosis of obstructive CAD or ANOCA/INOCA in individuals with an uncertain diagnosis on non-invasive testing 1.
From the Research
Diagnostic Tests for Coronary Artery Disease
The best test for coronary artery stenosis is a topic of ongoing research and debate. Several studies have compared the effectiveness of different diagnostic tests, including coronary computed tomographic angiography (CCTA), invasive coronary angiography (ICA), and functional stress testing.
Comparison of Diagnostic Tests
- CCTA has been shown to be a highly accurate test for detecting significant coronary stenosis, with a high sensitivity and specificity 2, 3.
- CCTA has also been compared to functional stress testing, with some studies suggesting that CCTA is associated with a reduced incidence of myocardial infarction, but an increased incidence of invasive coronary angiography and revascularization 4.
- ICA is still considered the gold standard for diagnosing coronary artery disease, but CCTA has been shown to be a valuable alternative, with lower radiation exposure and similar accuracy for predicting clinically driven revascularization 5.
- The Diamond and Forrester classification, which is commonly used to estimate the pretest probability of angiographically significant CAD, has been shown to overestimate the prevalence of CAD in patients referred for CCTA 6.
Key Findings
- CCTA is a highly accurate test for detecting significant coronary stenosis, with a high sensitivity and specificity.
- CCTA is associated with a reduced incidence of myocardial infarction, but an increased incidence of invasive coronary angiography and revascularization.
- ICA is still considered the gold standard for diagnosing coronary artery disease, but CCTA is a valuable alternative with lower radiation exposure and similar accuracy for predicting clinically driven revascularization.
- The Diamond and Forrester classification overestimates the prevalence of CAD in patients referred for CCTA.
Diagnostic Accuracy
- The diagnostic accuracy of CCTA has been evaluated in several studies, with area under the receiver operating characteristic curve (AUC) values ranging from 0.81 to 0.90 2, 3, 5.
- The AUC value for CCTA is similar to that of ICA, suggesting that CCTA is a valuable alternative for diagnosing coronary artery disease 5.