Clinical Value of Coronary Computed Tomographic Angiography in Patients With Stable Angina

Over the past decades, great strides have been made to establish coronary computed tomographic (CT) angiography within the field of cardiovascular medicine. The diagnostic accuracy of CT in comparison with invasive angiography was demonstrated in numerous single- and multicenter studies.1 From large registry data, an understanding developed of how cardiac CT could affect therapeutic management within different clinical contexts. Most recent clinical practice guidelines support the use of cardiac CT as a primary or secondary diagnostic option for patients with stable chest pain symptoms.2,3 As a last step toward full recognition, several randomized clinical trials were conducted to investigate the effect of cardiac CT on clinical outcome in comparison with established noninvasive strategies.4–7See Article by Bittencourt et al this issue of Circulation: Cardiovascular Imaging , Bittencourt et al8 performed a meta-analysis of all randomized controlled trials published until March 2015 that compared the clinical effectiveness of coronary CT angiography to other noninvasive strategies, and could make several interesting observations for which the separate trials had insufficient power. Although none of the trials demonstrated a statistically significant difference in hard end points, pooling of data from 14 817 patients in this meta-analysis demonstrated that implementation of cardiac CT was associated with a 31% lower myocardial infarction rate compared with usual care. For mortality, no significant difference could be demonstrated between both strategies. Cardiac CT also led to more revascularization procedures (77%), as well as a trend toward more invasive angiograms. We can only speculate whether there is a direct relation between the higher revascularization rate and the lower incidence of myocardial infarction, as other factors may be involved. At first glance the designs of the respective studies seem too different to combine. In terms of size Prospective Multicenter Imaging Study for Evaluation …