• Andrea Zito, Mattia Galli, Giuseppe Biondi-Zoccai, Antonio Abbate, Pamela S Douglas, Giuseppe Princi, Domenico D'Amario, Cristina Aurigemma, Enrico Romagnoli, Carlo Trani, and Francesco Burzotta.
• Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Rome, Italy (A.Z., G.P.).
• Ann. Intern. Med. 2023 Jun 1; 176 (6): 817826817-826.

BackgroundThere is uncertainty about which diagnostic strategy for detecting coronary artery disease (CAD) provides better outcomes.PurposeTo compare the effect on clinical management and subsequent health effects of alternative diagnostic strategies for the initial assessment of suspected stable CAD.Data SourcesPubMed, Embase, and Cochrane Central Register of Controlled Trials.Study SelectionRandomized clinical trials comparing diagnostic strategies for CAD detection among patients with symptoms suggestive of stable CAD.Data ExtractionThree investigators independently extracted study data.Data SynthesisThe strongest available evidence was for 3 of the 6 comparisons: coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA) (4 trials), CCTA versus exercise electrocardiography (ECG) (2 trials), and CCTA versus stress single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) (5 trials). Compared with direct ICA referral, CCTA was associated with no difference in cardiovascular death and myocardial infarction (relative risk [RR], 0.84 [95% CI, 0.52 to 1.35]; low certainty) but less index ICA (RR, 0.23 [CI, 0.22 to 0.25]; high certainty) and index revascularization (RR, 0.71 [CI, 0.63 to 0.80]; moderate certainty). Moreover, CCTA was associated with a reduction in cardiovascular death and myocardial infarction compared with exercise ECG (RR, 0.66 [CI, 0.44 to 0.99]; moderate certainty) and SPECT-MPI (RR, 0.64 [CI, 0.45 to 0.90]; high certainty). However, CCTA was associated with more index revascularization (RR, 1.78 [CI, 1.33 to 2.38]; moderate certainty) but less downstream testing (RR, 0.56 [CI, 0.45 to 0.71]; very low certainty) than exercise ECG. Low-certainty evidence compared SPECT-MPI versus exercise ECG (2 trials), SPECT-MPI versus stress cardiovascular magnetic resonance imaging (1 trial), and stress echocardiography versus exercise ECG (1 trial).LimitationMost comparisons primarily rely on a single study, many studies were underpowered to detect potential differences in direct health outcomes, and individual patient data were lacking.ConclusionFor the initial assessment of patients with suspected stable CAD, CCTA was associated with similar health effects to direct ICA referral, and with a health benefit compared with exercise ECG and SPECT-MPI. Further research is needed to better assess the relative performance of each diagnostic strategy.Primary Funding SourceNone. (PROSPERO: CRD42022329635).

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