Article type
Abstract
Background: The 2019 European Society of Cardiology (ESC) guidelines recommend the use of an imaging diagnostic test, such as Coronary Computed Tomography Angiography (CCTA), as the initial noninvasive test for diagnosing obstructive coronary artery disease (CAD). Current clinical practice in primary care in Region Stockholm is to refer patients with low clinical risk of CAD to exercise electrocardiography (ECG).
Objectives: To assess the effects of using CCTA compared to exercise ECG, as the initial test for diagnosing patients with suspected CAD, on cardiovascular events and mortality.
Methods: The literature was systematically searched up to October 2023 in 3 databases (PubMed, Embase and Cochrane Library). Two authors independently screened abstracts and full-texts for relevance and evaluated the risk of bias using RoB2 or ROBINS-I. Results were synthesized using meta-analyses. The certainty of the evidence was assessed using GRADE and we used a minimally important difference of 1%.
Results: We screened 10 019 records and included 3 RCT and 2 NRSI. Meta-analyses of the results from the RCTs resulted in no statistically significant differences in mortality (RR 1.06 (95% CI 0.37 to 3.06)) or myocardial infarction (RR 0.68 (95% CI 0.18 to 2.56) up to two years of follow up. Due to low baseline risks, the absolute effects were relatively precise for both outcomes (RD 0.00 (95% CI -0.01 to 0.01). Our GRADE assessment is that, for patients with a low clinical likelihood of CAD, using CCTA as the initial test instead of exercise ECG probably has little or no effect on mortality and myocardial infarctions up to two years.
Conclusions: Our results indicate that there will be little advantages of replacing exercise ECG with CCTA for patients with low risk of CAD. However, as we will discuss at the Colloquium, the results address a wider issue of over diagnosis since the baseline risks are similar to those in the general population.
Relevance and importance to patients: cardiovascular diseases remain a leading cause of morbidity and mortality globally, necessitating effective diagnostic tools for timely intervention, while ensuring that risks related to tests are appropriately weighed against the benefits to the individual.
Objectives: To assess the effects of using CCTA compared to exercise ECG, as the initial test for diagnosing patients with suspected CAD, on cardiovascular events and mortality.
Methods: The literature was systematically searched up to October 2023 in 3 databases (PubMed, Embase and Cochrane Library). Two authors independently screened abstracts and full-texts for relevance and evaluated the risk of bias using RoB2 or ROBINS-I. Results were synthesized using meta-analyses. The certainty of the evidence was assessed using GRADE and we used a minimally important difference of 1%.
Results: We screened 10 019 records and included 3 RCT and 2 NRSI. Meta-analyses of the results from the RCTs resulted in no statistically significant differences in mortality (RR 1.06 (95% CI 0.37 to 3.06)) or myocardial infarction (RR 0.68 (95% CI 0.18 to 2.56) up to two years of follow up. Due to low baseline risks, the absolute effects were relatively precise for both outcomes (RD 0.00 (95% CI -0.01 to 0.01). Our GRADE assessment is that, for patients with a low clinical likelihood of CAD, using CCTA as the initial test instead of exercise ECG probably has little or no effect on mortality and myocardial infarctions up to two years.
Conclusions: Our results indicate that there will be little advantages of replacing exercise ECG with CCTA for patients with low risk of CAD. However, as we will discuss at the Colloquium, the results address a wider issue of over diagnosis since the baseline risks are similar to those in the general population.
Relevance and importance to patients: cardiovascular diseases remain a leading cause of morbidity and mortality globally, necessitating effective diagnostic tools for timely intervention, while ensuring that risks related to tests are appropriately weighed against the benefits to the individual.