Aims: To determine the ranges of pre-test probability (PTP) of coronary arterydisease (CAD) in which stress electrocardiogram (ECG), stress echocardiography,coronary computed tomography angiography (CCTA), single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magneticresonance (CMR) can reclassify patients into a post-test probability that defines(>85%) or excludes (<15%) anatomically (defined by visual evaluation of invasive coronary angiography [ICA]) and functionally (defined by a fractional flowreserve [FFR] ≤0.8) significant CAD.Methods and results: A broad search in electronic databases until August 2017 wasperformed. Studies on the aforementioned techniques in >100 patients with stable CAD that utilized either ICA or ICA with FFR measurement as reference, wereincluded. Study-level data was pooled using a hierarchical bivariaterandom-effects model and likelihood ratios were obtained for each technique. The PTP ranges for each technique to rule-in or rule-out significant CAD weredefined. A total of 28 664 patients from 132 studies that used ICA as referenceand 4131 from 23 studies using FFR, were analysed. Stress ECG can rule-in andrule-out anatomically significant CAD only when PTP is ≥80% (76-83) and ≤19%(15-25), respectively. Coronary computed tomography angiography is able torule-in anatomic CAD at a PTP ≥58% (45-70) and rule-out at a PTP ≤80% (65-94).The corresponding PTP values for functionally significant CAD were ≥75% (67-83)and ≤57% (40-72) for CCTA, and ≥71% (59-81) and ≤27 (24-31) for ICA,demonstrating poorer performance of anatomic imaging against FFR. In contrast,functional imaging techniques (PET, stress CMR, and SPECT) are able to rule-infunctionally significant CAD when PTP is ≥46-59% and rule-out when PTP is≤34-57%.Conclusion: The various diagnostic modalities have different optimal performance ranges for the detection of anatomically and functionally significant CAD. StressECG appears to have very limited diagnostic power. The selection of a diagnostic technique for any given patient to rule-in or rule-out CAD should be based on theoptimal PTP range for each test and on the assumed reference standard.
The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability
Rutjes A;
2018-01-01
Abstract
Aims: To determine the ranges of pre-test probability (PTP) of coronary arterydisease (CAD) in which stress electrocardiogram (ECG), stress echocardiography,coronary computed tomography angiography (CCTA), single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magneticresonance (CMR) can reclassify patients into a post-test probability that defines(>85%) or excludes (<15%) anatomically (defined by visual evaluation of invasive coronary angiography [ICA]) and functionally (defined by a fractional flowreserve [FFR] ≤0.8) significant CAD.Methods and results: A broad search in electronic databases until August 2017 wasperformed. Studies on the aforementioned techniques in >100 patients with stable CAD that utilized either ICA or ICA with FFR measurement as reference, wereincluded. Study-level data was pooled using a hierarchical bivariaterandom-effects model and likelihood ratios were obtained for each technique. The PTP ranges for each technique to rule-in or rule-out significant CAD weredefined. A total of 28 664 patients from 132 studies that used ICA as referenceand 4131 from 23 studies using FFR, were analysed. Stress ECG can rule-in andrule-out anatomically significant CAD only when PTP is ≥80% (76-83) and ≤19%(15-25), respectively. Coronary computed tomography angiography is able torule-in anatomic CAD at a PTP ≥58% (45-70) and rule-out at a PTP ≤80% (65-94).The corresponding PTP values for functionally significant CAD were ≥75% (67-83)and ≤57% (40-72) for CCTA, and ≥71% (59-81) and ≤27 (24-31) for ICA,demonstrating poorer performance of anatomic imaging against FFR. In contrast,functional imaging techniques (PET, stress CMR, and SPECT) are able to rule-infunctionally significant CAD when PTP is ≥46-59% and rule-out when PTP is≤34-57%.Conclusion: The various diagnostic modalities have different optimal performance ranges for the detection of anatomically and functionally significant CAD. StressECG appears to have very limited diagnostic power. The selection of a diagnostic technique for any given patient to rule-in or rule-out CAD should be based on theoptimal PTP range for each test and on the assumed reference standard.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
