Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: Meta-analysis of individual patient data

Haase R, Schlattmann P, Gueret P, Andreini D, Pontone G, Alkadhi H, Hausleiter J, Garcia MJ, Leschka S, Meijboom WB, Zimmermann E, Gerber B, Schoepf UJ, Shabestari AA, Nørgaard BL, Meijs MF, Sato A, Ovrehus KA, Diederichsen AC, Jenkins SM, Knuuti J, Hamdan A, Halvorsen BA, Mendoza-Rodriguez V, Rochitte CE, Rixe J, Wan YL, Langer C, Bettencourt N, Martuscelli E, Ghostine S, Buechel RR, Nikolaou K, Mickley H, Yang L, Zhang Z, Chen MY, Halon DA, Rief M, Sun K, Hirt-Moch B, Niinuma H, Marcus RP, Muraglia S, Jakamy R, Chow BJ, Kaufmann PA, Tardif JC, Nomura C, Kofoed KF, Laissy JP, Arbab-Zadeh A, Kitagawa K, Laham R, Jinzaki M, Hoe J, Rybicki FJ, Scholte A, Paul N, Tan SY, Yoshioka K, Röhle R, Schuetz GM, Schueler S, Coenen MH, Wieske V, Achenbach S, Budoff MJ, Laule M, Newby DE, Dewey M (2019)

Publication Type: Journal article

Publication year: 2019


Book Volume: 365

Article Number: el1945

DOI: 10.1136/bmj.l1945


Objective To determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups of patients. Design Prospectively designed meta-analysis of individual patient data from prospective diagnostic accuracy studies. Data sources Medline, Embase, and Web of Science for published studies. Unpublished studies were identified via direct contact with participating investigators. Eligibility criteria for selecting studies Prospective diagnostic accuracy studies that compared coronary CTA with coronary angiography as the reference standard, using at least a 50% diameter reduction as a cutoff value for obstructive CAD. All patients needed to have a clinical indication for coronary angiography due to suspected CAD, and both tests had to be performed in all patients. Results had to be provided using 2×2 or 3×2 cross tabulations for the comparison of CTA with coronary angiography. Primary outcomes were the positive and negative predictive values of CTA as a function of clinical pretest probability of obstructive CAD, analysed by a generalised linear mixed model; calculations were performed including and excluding non-diagnostic CTA results. The no-treat/treat threshold model was used to determine the range of appropriate pretest probabilities for CTA. The threshold model was based on obtained post-test probabilities of less than 15% in case of negative CTA and above 50% in case of positive CTA. Sex, angina pectoris type, age, and number of computed tomography detector rows were used as clinical variables to analyse the diagnostic performance in relevant subgroups. Results Individual patient data from 5332 patients from 65 prospective diagnostic accuracy studies were retrieved. For a pretest probability range of 7-67%, the treat threshold of more than 50% and the no-treat threshold of less than 15% post-test probability were obtained using CTA. At a pretest probability of 7%, the positive predictive value of CTA was 50.9% (95% confidence interval 43.3% to 57.7%) and the negative predictive value of CTA was 97.8% (96.4% to 98.7%); corresponding values at a pretest probability of 67% were 82.7% (78.3% to 86.2%) and 85.0% (80.2% to 88.9%), respectively. The overall sensitivity of CTA was 95.2% (92.6% to 96.9%) and the specificity was 79.2% (74.9% to 82.9%). CTA using more than 64 detector rows was associated with a higher empirical sensitivity than CTA using up to 64 rows (93.4% v 86.5%, P=0.002) and specificity (84.4% v 72.6%, P<0.001). The area under the receiver-operating-characteristic curve for CTA was 0.897 (0.889 to 0.906), and the diagnostic performance of CTA was slightly lower in women than in with men (area under the curve 0.874 (0.858 to 0.890) v 0.907 (0.897 to 0.916), P<0.001). The diagnostic performance of CTA was slightly lower in patients older than 75 (0.864 (0.834 to 0.894), P=0.018 v all other age groups) and was not significantly influenced by angina pectoris type (typical angina 0.895 (0.873 to 0.917), atypical angina 0.898 (0.884 to 0.913), non-anginal chest pain 0.884 (0.870 to 0.899), other chest discomfort 0.915 (0.897 to 0.934)). Conclusions In a no-treat/treat threshold model, the diagnosis of obstructive CAD using coronary CTA in patients with stable chest pain was most accurate when the clinical pretest probability was between 7% and 67%. Performance of CTA was not influenced by the angina pectoris type and was slightly higher in men and lower in older patients. Systematic review registration PROSPERO CRD42012002780.

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Involved external institutions

Charité - Universitätsmedizin Berlin DE Germany (DE) Universitätsklinikum Jena DE Germany (DE) Paris-Est Créteil University / Université Paris-Est Créteil Val-de-Marne (UPEC) / Université Paris XII-Val-de-Marne / University Paris 12 Marne la Vallée FR France (FR) Università degli studi di Milano IT Italy (IT) Centro Cardiologico Monzino (IRCCS) IT Italy (IT) Universitätsspital Zürich (USZ) CH Switzerland (CH) Klinikum der Universität München DE Germany (DE) Albert Einstein College of Medicine US United States (USA) (US) Kantonsspital St.Gallen CH Switzerland (CH) Erasmus University Medical Center (MC) NL Netherlands (NL) Cliniques universitaires Saint-Luc (CHU St-Luc) BE Belgium (BE) Medical University of South Carolina (MUSC) US United States (USA) (US) Shahid Beheshti University of Medical Sciences IR Iran, Islamic Republic of (IR) Aarhus University Hospital / Aarhus Universitetshospital DK Denmark (DK) University Medical Centre Utrecht (UMC Utrecht) NL Netherlands (NL) University of Tsukuba / 筑波大学 JP Japan (JP) Odense Universitetshospital (OUH) DK Denmark (DK) Glasgow Royal Infirmary (GRI) GB United Kingdom (GB) Turku University Hospital / Turun yliopistollinen keskussairaala (TYKS) FI Finland (FI) Tel Aviv University IL Israel (IL) Østfold Hospital Trust / Sykehuset Østfold NO Norway (NO) national institute of cardiology and cardiovascular surgery CA Canada (CA) HCor - Hospital do Coração, São Paulo, Brasil BR Brazil (BR) Kerckhoff-Klinik DE Germany (DE) Chang Gung University (CGU) / 長庚大學 TW Taiwan (TW) Universitätsklinikum Knappschaftskrankenhaus Bochum DE Germany (DE) Centro Hospitalar Vila Nova de Gaia PT Portugal (PT) Università degli Studi di Roma 'Tor Vergata' IT Italy (IT) Hôpital Marie Lannelongue FR France (FR) Universitätsklinikum Tübingen DE Germany (DE) University of Edinburgh GB United Kingdom (GB) Beijing Anzhen Hospital CN China (CN) National Heart, Lung, and Blood Institute (NHLBI) US United States (USA) (US) Carmel Medical Center IL Israel (IL) Baotou Central Hospital CN China (CN) St. Luke's International Hospital JP Japan (JP) Ospedale Santa Chiara IT Italy (IT) Pitié-Salpêtrière University Hospital / Hôpital universitaire Pitié-Salpêtrière FR France (FR) University of Ottawa CA Canada (CA) Institut de Cardiologie de Montréal CA Canada (CA) Hospital Israelita Albert Einstein BR Brazil (BR) University of Copenhagen DK Denmark (DK) Hôpital Bichat-Claude-Bernard (CHU, APHP) FR France (FR) Johns Hopkins Hospital US United States (USA) (US) Hospital Universitário de Mie JP Japan (JP) Veterans Affairs Healthcare System Boston and Harvard Medical School US United States (USA) (US) Keio University Hospital JP Japan (JP) Mount Elizabeth Medical Centre SG Singapore (SG) Leiden University Medical Center NL Netherlands (NL) Western University CA Canada (CA) National Heart Research Institute Singapore (NHRIS) SG Singapore (SG) Iwate Medical University JP Japan (JP) University of California Los Angeles (UCLA) US United States (USA) (US)

How to cite


Haase, R., Schlattmann, P., Gueret, P., Andreini, D., Pontone, G., Alkadhi, H.,... Dewey, M. (2019). Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: Meta-analysis of individual patient data. British Medical Journal, 365. https://doi.org/10.1136/bmj.l1945


Haase, Robert, et al. "Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: Meta-analysis of individual patient data." British Medical Journal 365 (2019).

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