Further information: Exercise Testing (see p729),
Coronary Angiography (see p745),
Echocardiographic Evaluation of Coronary Artery Disease (see p811)
and Myocardial Perfusion Imaging Utilizing Single Photon Emission Computed Tomography Techniques (see p841) from Cardiovascular Medicine, 3rd Edn*

At University Medical Center in Rotterdam, The Netherlands, investigators conducted an observational study [1] to compare the accuracy of noninvasive diagnostic testing in the diagnosis of coronary artery disease (CAD) in patients with chest symptoms. The reference standard for diagnosing CAD is invasive coronary angiography (ICA), an expensive test when compared to noninvasive diagnostic testing. Noninvasive diagnostic stress tests include exercise electrocardiography (ECG), single-photon emission computed tomography (SPECT), or stress echocardiography, and while these tests are less expensive, they are also less accurate. A newer noninvasive diagnostic test is computed tomography coronary angiography (CTCA).

The purpose of the study was to compare the accuracy and clinical utility of CTCA with stress testing when determining which patients required invasive testing. In two enrollment periods, investigators enrolled 517 patients who had been referred to the medical center by their physicians. The first group of 297 patients underwent stress testing, CTCA, and ICA. The second group of 220 patients underwent stress testing and CTCA.

Investigators concluded that in patients with low pretest probability of CAD, stress testing was adequate as a first diagnostic test. They determined that CTCA was more accurate when used in patients with a pretest intermediate probability because it was better able to determine which patients required invasive testing. In patients with a high pretest probability, neither stress testing nor CTCA served as an additional diagnostic tool, and physicians should prescribe ICA immediately.

[1] Weustink AC, Mollet NR, Neefjes LA, et al. Diagnostic accuracy and clinical utility of noninvasive testing for coronary artery disease. Ann Intern Med 2010;152:630-39

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