Linking To And Excerpting From “SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography”

Posted on May 4, 2026 by Tom Wade MD

Today, I review, link to and excerpt from SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. J Cardiovasc Comput Tomogr. 2021 May-Jun;15(3):192-217. doi: 10.1016/j.jcct.2020.11.001. Epub 2020 Nov 20.

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1. Introduction: scope of the document

Cardiac computed tomography (CT) has changed rapidly since the last major guideline from SCCT. While there have been significant advances in technology, the most gratifying part has been the development of a robust evidence base for the use of cardiac CT in diagnoses of heart disease, prognostication and modulating therapy (both medical and interventional). Such a systematic development of knowledge base has not been the usual practice for any other imaging modality before widespread clinical acceptance in the past. It is no surprise that major guideline bodies have started to endorse incorporation of cardiac CT more definitively than before, and some, like the NICE guidelines in the UK, have even given it first line status. While CTA has been shown to be very good for prognosticating risk, excluding significant coronary artery disease (CAD) in stable patients with chest pain and has high sensitivity for the identification of significant coronary stenoses, it is somewhat less robust in specificity and positive predictive accuracy, leading to the development of value added CT angiography (CTA) strategies like fractional flow reserve derived from CT (CT-FFR) and CT perfusion (CTP); these have arrived into the clinical arena since the last guidelines and, more importantly, have produced a large volume of scientific data showing significant clinical utility. Finally, some questions that often arise in regular clinical practice lack robust trial based evidence and a considered expert opinion might help the clinician make appropriate decisions in everyday practice. It is thus clear that an updated scholarly compendium of recent data is needed to bridge the knowledge gap since the last iteration of the SCCT guideline documents. This SCCT consensus statement summarizes current evidence, updates previous recommendations, addresses key questions regarding the use of CTA in multiple different cardiac scenarios and brings together the collective corpus of literature in the form of definitive recommendations. CTA in acute coronary syndromes will be presented in a separate document. The Expert Consensus recommendations are summarized in Table 1 and Fig. 1.

Table 1.

SCCT coronary CTA expert consensus recommendations.

Evaluation of Stable Coronary Artery Disease: Coronary CTA in Native Vessels

  • It is appropriate to perform CTA as the first line test for evaluating patients with no known CAD who present with stable typical or atypical chest pain, or other symptoms which are thought to represent a possible anginal equivalent (e.g., dyspnea on exertion, jaw pain).

  • It is appropriate to perform CTA as a first line test for evaluating patients with known CAD who present with stable typical or atypical chest pain, or other symptoms which are thought to represent a possible anginal equivalent (e.g., dyspnea on exertion, jaw pain).

  • It is appropriate to perform coronary CTA following a non-conclusive functional test, in order to obtain more precision regarding diagnosis and prognosis, if such information will influence subsequent patient management.

  • It is recommended to perform CTA as the first line test when considering evaluation for revascularization strategies using the ISCHEMIA Trial.

  • It may be appropriate to perform CTA in selected asymptomatic high risk individuals, especially in those who have a higher likelihood of having a large amount of non-calcified plaque

  • It is rarely appropriate to perform coronary CTA in very low risk symptomatic patients, e.g., <40 years of age with non-cardiac symptoms (chest wall pain, pleuritic chest pain).

  • It is rarely appropriate to perform CTA in low- and intermediate risk asymptomatic patients.
Evaluation of Stable Coronary Artery Disease: Coronary CTA Post Revascularization

  • It is appropriate to perform coronary CTA in symptomatic patients with intracoronary stent diameter ≥3.0 mm. Measures to improve accuracy of stent imaging should be utilized, to include strict heart rate control (goal <60 bpm), iterative reconstruction, sharp kernel reconstruction, and mono-energetic reconstructions (when available). Protocols to optimize stent imaging should be developed and followed.

  • It may be appropriate to perform coronary CTA in symptomatic patients with stents <3.0 mm, especially those known to have thin stent struts (<100 mm) in proximal, non-bifurcation locations.

  • It is appropriate to perform CTA for evaluation of patients with prior CABG, particularly if graft patency is the primary objective.

  • It is appropriate to perform CTA to visualize grafts and other structures prior to re-do cardiac surgery.

Evaluation of Stable Coronary Artery Disease: Coronary CTA with FFR or CTP

  • It may be appropriate to perform CT derived FFR and CT myocardial perfusion Imaging to evaluate the functional significance of intermediate stenoses on CTA (30e90% diameter stenosis) particularly in the setting of multivessel disease to help guide ICA referral and revascularization treatment planning. LM stenosis≥50% and severe triple vessel disease should undergo invasive coronary angiography.

  • Adding FFRCT and stress-CTP to CTA increases specificity, positive predictive value, and diagnostic accuracy over regular CTA.

  • FFRCT and stress-CTP may be largely comparable in diagnostic utility. CTP is a potentially valuable alternative particularly when CT-FFR is technically difficult (e.g., suboptimal CTA quality, prior revascularization).

Evaluation of Stable Coronary Artery Disease: Coronary CTA in Other Conditions

  • It is appropriate to perform CTA for coronary artery evaluation prior to noncoronary cardiac surgery as an equivalent alternative to invasive angiography in selected patients, e.g., low-intermediate probability of CAD, younger patients with primarily non-degenerative valvular conditions.

  • CTA may be considered an appropriate alternative to other noninvasive tests for evaluation of selected patients prior to noncardiac surgery.

  • It is appropriate to perform CTA to exclude coronary artery disease in patients with suspected non-ischemic cardiomyopathy.

  • It may be appropriate to perform late enhancement CT imaging to detect infiltrative heart disease or scar in selected patients who have non-ischemic or ischemic cardiomyopathy and who cannot undergo cardiac MRI. Such imaging may be performed if it has the potential to impact the diagnosis and/or treatment (e.g. planning for ablation therapy).

  • It may be appropriate to perform CTA as an alternative to invasive coronary angiography for the screening of patients for coronary allograft vasculopathy in selected clinical practice settings.

  • It is appropriate to perform CTA for the evaluation of coronary anomalies.

  • It is appropriate to EKG gate aortic dissection and aneurysm CTA, as well as pulmonary embolus studies in men >45 years and women >55 years, and analyze and report the coronary arteries.

  • CTA with a limited delayed image (60e90 sec) is an appropriate alternative to TEE when the primary aim is to exclude LA/LAA thrombus and in patients where the risks associated with TEE outweigh the benefits. In all situations CTA and TEE should be discussed with the patient in the setting of shared decision making.

  • It may be appropriate to perform late enhancement CT imaging for the evaluation of myocardial viability in selected patients who cannot undergo cardiac MRI. Such imaging may be performed if it has the potential to impact the diagnosis and/or treatment (e.g. planning for revascularization).

Reporting on CTA: Coronary and Non Coronary Information

  • The CAD-RADs reporting is recommended.

  • It is appropriate to report prior myocardial infarction when its features are evident on CTA.

  • It is appropriate to report remote myocardial infarction when fatty metaplasia or calcification within an area of infarction are present.

Fig. 1.

Fig. 1.

Central Illustration Role of CTA in chronic CAD. Also please see Table 1.

2. Evidence base

2.1. Diagnostic accuracy

2.1.1. Introduction

Since the recognition that coronary artery stenoses can produce chest pain, the imperative has been to identify through noninvasive testing both the patients whose chest pain is ischemic in etiology, and, with a view towards revascularization, the arteries and specific stenoses that are responsible for the ischemia. To fulfill this need, testing has evolved from simple exercise treadmill test (ETT) to (a) Measures estimating myocardial blood flow changes: myocardial perfusion imaging by single photon emission computed tomography (SPECT), positron emission tomography (PET), magnetic resonance imaging (MRI), (b) Measures detecting the functional consequence of reduced myocardial blood flow: stress echocardiography (SE), (c) Anatomic Imaging: CTA, and finally (d). Combination of anatomic coronary imaging coupled with physiology or perfusion: CTA derived fractional flow reserve (FFRCT) and CTP. How these modalities compare with each other has important implications for diagnostic strategies.

The gold standard for determining ischemia has also evolved from percent diameter stenosis (DS) on invasive coronary angiography (ICA) to more physiologic measures, such as invasive fractional flow reserve (FFR) that better reflect coronary blood flow and inducible ischemia. Using DS as a reference standard often provides an inaccurate assessment of ischemia. For instance, when compared to invasive FFR ≤0.80, the sensitivity of ICA is 69%, and the specificity is 67%. Although invasive FFR was initially validated by functional noninvasive testing (SPECT and SE), this method has become a universally accepted gold standard by virtue of its strong association with outcomes.– Nonetheless, %DS continues to be used much more often than invasive FFR before percutaneous coronary intervention (PCI), – In the ALKK Registry in Germany, FFR was performed in only 3.3% of 40,160 patients undergoing ad hoc PCI from 2010 to 2013. There has been an increase in invasive FFR use in the US, from 8.1% in 2010 to 30.8% in 2014, in a registry of 397,737 patients undergoing nonacute PCI. Consequently, the noninvasive imaging modalities will be compared to both %DS and FFR. The best level of evidence is provided by meta-analyses, which will serve as the basis for comparisons, with the exception of 2 recent single center studies not included in meta-analyses. The meta-analyses included patients with and without confirmed CAD and did not draw distinctions between them.

2.1.2. Diagnostic performance of functional imaging and CTA compared to >50% diameter stenosis by ICA

The National Cardiovascular Data Registry suggested that functional testing is suboptimal for detecting significant coronary stenoses. Of the 661,063 patients undergoing elective catheterization, 64% had testing before the invasive coronary angiogram (ICA); of those, only 51.9% were abnormal. The percentages of patients with <50% DS on subsequent ICA ranged from 55 to 56% after an abnormal exercise treadmill test (ETT), stress echocardiography (SE), single photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI); for resting CTA, the percentage was 30%. In the oldest report, Fleischmann et al. evaluated 5874 patients in 41 studies from 1990 to 1997, and reported sensitivity and specificity of 85% and 77% for SE and 87% and 64% for SPECT, with 52% and 71% for exercise ECG. DeJong et al. (Table 2A), in a meta-analysis of 5088 patients in 51 studies from 2000 to 2011 evaluated MRI, SE and SPECT with >50%DS by ICA as reference. MRI was the most sensitive and specific (91% and 80%), with SE (87% and 72%) and SPECT (83% and 77%) roughly similar. Jaarsma et al. (Table 2B), reported on SPECT, MRI and positron emission tomography (PET) in 141 per-patient studies and 70 per-vessel studies. Per-patient diagnostic odds ratio (DOR) was highest for PET (36.47) followed by MRI (26.42) and SPECT (16.31). In per-vessel analysis, PET and MRI were equal (24.74 and 24.11), while SPECT was lowest (11.75). In a meta-analysis limited to 26 studies in which CTA was compared to either ETT or SPECT in the same group of patients, Nielsen et al. (Table 2C) reported CTA sensitivities of 95–99%, specificities of 68–93% and DOR of 128–728. Corresponding ranges for ETT were 65–70%, 24–60% and 0.7–4 and for SPECT were 67–73%, 48–52% and 2–4. It is important to understand that available meta-analyses are also challenged by the small numbers of patients in some of the individual reports, potential referral bias, and often include a mixture of newer and older technology (e.g., planar and SPECT imaging). Finally, in a paper published too recently for meta-analysis inclusion, 391 symptomatic patients, 52% with intermediate and 46% with high risk pre-test probability, who were scheduled for ICA, underwent both CTA and SPECT with >50%DS by ICA as reference. Sensitivity, specificity, positive and negative predictive values were 0.92, 0.75, 0.84 and 0.87 for CTA and 0.62, 0.68, 0.74 and 0.55 for SPECT. AUC was significantly higher for CTA (0.91 versus 0.69, p < 0.001.

Table 2.

Meta-analyses of the diagnostic performance of functional imaging and CCTA with ICA >50%DS as reference standarda.

A. MRI, SE and SPECT
Sensitivity Specificity PLR NLR DOR
MRI (n = 2970) Overall 91% 80% 4.43 0.12 37.69
Suspected 90% 86% 6.61 0.12 54.70
CAD>50% 89% 79% 4.25 0.13 31.84
CAD>70% 91% 82% 4.97 0.11 46
SE (n = 795) Overall 87% 72% 3.08 0.18 16.94
Suspected 88% 89% 8.35 0.13 62.76
CAD>50% 86% 74% 3.28 0.19 17.59
CAD>70% 90% 65% 2.58 0.15 17.04
SPECT (n = 1323) Overall 83% 77% 3.56 0.22 15.84
Suspected 83% 79% 3.88 0.21 18.15
CAD>50% 81% 81% 4.15 0.24 17.24
CAD>70% 85% 66% 2.53 0.22 11.42
B. SPECT, MRI and PET
No. of studies Sensitivity Specificity DOR
Patient
SPECT 105 88% 61% 15.31
MRI 27 89% 76% 26.42
PET 11 84% 81% 36.47
Territory
SPECT 46 69% 79% 11.75
MRI 17 84% 83% 24.11
PET 7 77% 88% 24.74
C. CCTA, XECG and SPECT
No. studies Sensitivity Specificity PPV NPV DOR
CCTA vs ETT 7
 CTA 98% 87% 85 97.5 221
 ETT 67% 46% 41 72 2
CCTA vs ETT (ICA in all) 5
 CCTA 99% 88% 89% 99% 728
 ETT 68% 39% 50% 51% 1.2
CCTA vs ETT (inconclusive excluded) 4
 CCTA 98% 68% 75% 97% 128
 ETT 70% 60% 49.5% 78% 4
CCTA vs ETT (intention to diagnose) 3
 CCTA 95% 93% 93% 96% 192
 ETT 65% 24% 32% 55% 0.7
CCTA vs SPECT 5
 CCTA 99% 71% 91% 95.5% 172
 SPECT 73% 48% 80% 33% 2
CCTA vs SPECT (ICA in all) 2
 CCTA 99% 74% 91% 96% 228
 SPECT 67% 52% 78% 38%

Abbreviations: AUC = area under receiver operator characteristic curve, CAD = coronary artery disease.

DOR = diagnostic odds ratio, CTA = coronary computed tomographic angiography, MRI = stress magnetic resonance imaging, NLR = negative likelihood ratio, NPV = negative predictive value, PET = positron emission tomography, PLR = positive likelihood ratio, PPV = positive predictive value, SE = stress echocardiography, SPECT = single photon emission computed tomography myocardial perfusion imaging, XECG = exercise electrocardiogram.

a Reprinted with permission of Oxford Academic from Hecht et al. Eur Heart J 2019:40;1440–1453

2.1.3. Diagnostic performance of functional imaging and CTA compared to FFR

There have been several recent meta-analyses of the correlation between noninvasive testing and Invasive FFR ≤0.80. Takx et al. (Table 3A) compared multiple myocardial perfusion imaging modalities to FFR in 2048 patients and 4721 vessels in 37 studies. They reported the highest areas under the receiver operator characteristic curve (AUC) per patient for CTP (0.93), PET (0.93) and MRI (0.94) compared to SPECT (0.82) and SE (0.83). Similarly, the highest per vessel sensitivities were for MRI (89%), CTP (88%) and PET (84%) compared to SE (69%) and SPECT (74%). Specificities were similar for all modalities, ranging from 79% for SPECT to 87% for PET, with 80% for CTP and 84% for SE and MRI.

Table 3.

Meta-analyses of the diagnostic performance of functional imaging and CCTA with FFR ≤0.80 as reference standarda.

A. CTP, SPECT, SE, MRI, PET
Index test N Sensitivity Specificity PLR NLR AUC
 Patients
  CTP 316 88% 80% 3.79 0.12 0.93
  SPECT 533 74% 79% 3.13 0.39 0.82
  SE 177 69% 84% 3.68 0.42 0.83
  MRI 798 89% 84% 6.29 0.14 0.94
  PET 224 84% 87% 6.53 0.14 0.93
  Vessels
  CTP 1074 78% 86% 5.74 0.22 0.91
  SPECT 924 81% 84% 3.76 0.47 0.83
  SE NA – – – – –
  MRI 1830 83% 89% 8.27 0.16 0.95
  PET 870 83% 89% 7.43 0.15 0.95
B. CCTA, SE, FFRCT, ICA, MRI, and SPECT
Index test N Sensitivity Specificity PLR NLR DOR AUC
 Patients
  CCTA 694 90% 39% 1.54 0.22 6.91 0.57
  FFRCT 609 90% 78% 3.34 0.16 21.94 0.94
  SPECT 110 70% 78% 3.40 0.40 9.06 0.79
  SE 115 77% 75% 3.00 0.34 9.51 0.82
  MRI 70 90% 94% 10.31 0.12 92.15 0.94
  ICA 954 69% 67% 2.52 0.46 5.46 0.79
 Vessels
  CCTA 2085 91% 51% 2.09 0.17 13.15 0.85
  FFRCT 1050 83% 78% 4.02 0.22 19.15 0.92
  SPECT 470 57% 75% 2.34 0.55 4.72 0.74
  SE NA – – – – – –
  MRI 371 91% 85% 6.16 0.11 73.53 0.97
  ICA 3196 71% 66% 2.26 0.45 5.34 0.76
C. CMR, FFRCT, CTP, DSE, PET and SPECT
Index test N Sensitivity Specificity PLR NLR DOR AUC
Patient
MRI 1054 88% 84% 5.62 0.14 40.69 0.91
FFRct 662 90% 75% 3.60 0.14 25.87 0.90
CTP 532 88% 87% 6.97 0.14 49.88 0.94
DSE 359 69% 77% 2.96 0.40 7.40 0.78
PET 609 90% 84% 6.00 0.12 56.59 0.92
SPECT 1142 78% 79% 3.76 0.28 13.52 0.85
Vessel
MRI 3260 87% 89% 8.15 0.14 57.93 0.94
FFRCT 2782 86% 83% 5.10 0.17 29.37 0.89
CTP 1444 89% 89% 7.82 0.13 61.98 0.94
DSE 94 62% 87% 4.66 0.44 10.51 0.86
PET 2017 86% 88% 7.15 0.17 42.39 0.92
SPECT 1288 72% 79% 3.45 0.36 9.71 0.83
D. CCTA, CTP and FFRCT
Index test N Sensitivity Specificity PLR NLR DOR PPV NPV
Per patient
CCTA 1039 92% 43% 1.64 0.19 9.17 57% 87%
CTP 187 94% 77 3.85 0.09 63.42 83% 92%
FFRCT 662 90% 72% 3.70 0.16 24.34 70% 90%
Per vessel
CCTA 1239 89% 65% 2.66 0.17 19.78 48% 94%
CTP 264 83% 76% 3.68 0.22 20.10 61% 91%
FFRCT 714 83% 77% 3.76 0.23 18.21 63% 91%
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Abbreviations: CTA = coronary computed tomographic angiography CTP = CT perfusion DOR = diagnostic odds ratio FFR = fractional flow reserve FFRCT = fractional flow reserve by computed tomography ICA = invasive coronary angiography MRI = stress magnetic resonance imaging NA = not available NLR = negative likelihood ratio NPV = negative predictive value PET = positron emission tomography PLR = positive likelihood ratio PPV = positive predictive value SE = stress echocardiography SPECT = single photon emission computed tomography myocardial perfusion imaging.

a Reprinted with permission of Oxford Academic from Hecht et al. Eur Heart J 2019:40;1440–1453.
A second meta-analysis, analyzing 3798 patients and 5323 vessels in 23 studies, by Danad et al., (Table 3B), excluded studies in which <75% of vessels were evaluated by FFR, included CTA >50% diameter stenosis and ICA >50%DS and excluded PET, for which there were not sufficient numbers after excluding studies with <75% of vessels having invasive FFR. Sensitivity was highest for CTA and MRI in both per patient (90%) and per vessel (91%) analyses. SPECT sensitivity was the lowest of the functional tests for both patients (70%) and vessels (57%) while SE was also suboptimal (77%). ICA sensitivity was dramatically lower (69%) than for CTA even though both depict coronary anatomy. Specificity was highest for MRI for both per patient (94%) and per vessel analysis (85%), followed by the other 2 functional modalities of SPECT and SE in the 75–78% range. CTA specificity was remarkably lower (39%) than both the functional tests and ICA (66%). The likelihood ratios and AUC reflect these differences; MRI was superior for both positive and negative likelihood ratios and AUC. CTA negative likelihood was excellent as well but had the lowest per patient and per vessel positive likelihood ratio and AUC. Comparison of the anatomical modalities indicates that %DS is overestimated by CTA and under-estimated by ICA, explaining the higher sensitivity and lower specificity for CTA.
A third meta-analysis of all the functional imaging modalities with considerably more patients, by Dai et al. (Table 3C) of 74 studies, included CTFFR and CTP and excluded solely anatomic CTA. As before, CTP, CTFFR CMR and PET had superior per patient sensitivity (88–90%), specificity (84–87%) and DOR (41–57). The 2 most frequently performed functional imaging modalities of SE and SPECT were the least accurate: 69% and 78% sensitivity, 77% and 79% specificity, and 7.40 and 13.40 DOR.
Finally, in the PACIFIC trial, a single center study of 208 patients who underwent CTA, SPECT, PET and ICA with FFR, CTA was 90% sensitive, 60% specific and 74% accurate, compared to 87%, 84% and 85% for PET and 57%, 94% and 77% for SPECT.
CT has 2 additional advantages in diagnosis and management of chronic stable CAD. It can prognosticate very well–, and has the unique ability to identify adverse coronary plaque characteristics that portend adverse risk– and might even influence the occurrence of ischemia (). Some of the newer value added technologies like CT-FFR and CTP (,) have now been shown to improve the accuracy of CAD diagnosis over and above CTA alone.
Addition of physiologic studies to anatomic information in the same CT scan improve test performance., The meta-analysis by Gonzalez et al., of 1535 patients in 18 studies, compared CTA, CTP and CT-FFR. Per patient sensitivities were similar (90–94%), but specificities (43%, 77% and 72%) and DOR (9.17, 63.42 and 24.34) were lowest for CTA without a functional imaging component. Per-vessel results were much less disparate, with sensitivities of 89%, 83% and 83%, specificities of 65%, 76% and 77%, and virtually identical DOR of 19.78, 20.10 and 18.21. A more recent meta-analysis (5330 patients) comparing CTA, CTP and CT-FFR also showed improved efficacy for diagnosing hemodynamically significant CAD compared with CTA alone with higher vessel level, pooled specificity with CTP (0.86; 95% confidence interval [CI]: 0.76 to 0.93), and CT-FFRCT (0.78; 95% CI: 0.72 to 0.83) than that of CTA (0.61; 95% CI: 0.54 to 0.68); addition of either FFRCT, or CTP to CTA improved specificities (0.80–0.92) and superior diagnostic accuracy for CTP, FFRCT, and combined CTA and CTP, compared with CTA. On-site FFR performed as well as off-site FFR and dynamic CTP was more sensitive (0.85 vs. 0.72), but less specific (0.81 vs. 0.90) than static CTP.
With few exceptions, these meta-analyses represent a compilation of prospective and retrospective single center studies with their implicit biases and general lack of direct inter-modality comparisons in the same group of patients. Nonetheless, they offer the most comprehensive evaluation by virtue of their large numbers, and the similarities of the findings irrespective of the inclusion criteria for the meta-analyses.

2.1.4. General conclusions

  1. With ICA >50%DS as the reference, CTA, MRI and PET are the most sensitive and specific modalities; SPECT and SE are less sensitive and specific.

  2. With invasive FFR ≤0.80 as the reference, CTA, MRI and PET are the most sensitive and MRI and PET are the most specific. CTA is the least specific but CT-FFR and CTP increase the specificity to the level of MRI and PET without loss of sensitivity. SPECT and SE are the least sensitive.

  3. These accuracy data should inform the suspected ischemia decision making process, which will also be strongly affected by the availability and expertise of the imaging centers, as well as by outcome and cost studies, some of which are already available after short term analysis.

  4. While proceeding to testing was predicated upon estimating pre test probability, the current practice patterns pose some challenges – patients are at lower risk than before and the percentage of positive tests is declining. Models for predicting pre test probability, derived from older data perform sub optimally, and therefore require an update. There is now a strong movement towards dispensing wth this completely as formulated in the NICE guidelines.

  5. Adding non CT modalities for myocardial perfusion (which have better specificity) to CTA (which has excellent sensitivity) is an attractive strategy to minimize the disadvantages of each technique but this has not worked out very well in practice; hybrid cardiac imaging improves diagnostic specificity but with only modest improvement in overall diagnostic performance.

2.2. Prognostic value and comparison with functional testing

The prognostic value of CTA has now been established in both large registry studies and more recent randomized controlled trials. This increasing depth of evidence highlights that CTA provides prognostic information for patents with all levels of cardiovascular risk. In addition, both normal and abnormal CTA results provide important information that can alter downstream investigations and management and influence subsequent outcomes. Our knowledge of the utility of CTA has moved beyond confirmation of diagnostic accuracy, with comparative effectiveness studies now underpinning the prognostic benefit of CTA in large randomized populations. The identification of both obstructive and non-obstructive coronary artery disease by CTA provides important information in patients with both stable chest pain and acute symptoms.

Registry studies have established the excellent prognostic value of a normal CTA, both for short-term outcomes and longer term mortality.– Previous analysis of stress myocardial perfusion imaging (MPI) identified that a normal study is associated with a low risk of subsequent major adverse cardiovascular events, equating to less than a 1% annual risk for patients without comorbidities. Similarly, a meta-analysis of patients 122,721 patients in 165 studies identified that a normal CTA (without plaque) in patients with suspected or known coronary artery disease (CAD) was associated with a low risk of subsequent events, which is below an annual event rate of 1%. This low event rate was maintained after correction for the underlying population event risk and the proportion of patients with CAD. After correction, the event rate for a normal CTA was similar to that of a normal SPECT, ETT, CMR, PET or stress echocardiogram. Indeed, a normal CTA is associated with an excellent prognosis extending beyond 5 years.– There is now data showing that a normal CTA strongly predicts event free survival even over a 10 year follow up.

 

 

 

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