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.
Knuuti, Juhani; Ballo, Haitham; Juarez-Orozco, Luis Eduardoet al.
[en] Aims: To determine the ranges of pre-test probability (PTP) of coronary artery disease (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 magnetic resonance (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 flow reserve [FFR] </=0.8) significant CAD. Methods and results: A broad search in electronic databases until August 2017 was performed. Studies on the aforementioned techniques in >100 patients with stable CAD that utilized either ICA or ICA with FFR measurement as reference, were included. Study-level data was pooled using a hierarchical bivariate random-effects model and likelihood ratios were obtained for each technique. The PTP ranges for each technique to rule-in or rule-out significant CAD were defined. A total of 28 664 patients from 132 studies that used ICA as reference and 4131 from 23 studies using FFR, were analysed. Stress ECG can rule-in and rule-out anatomically significant CAD only when PTP is >/=80% (76-83) and </=19% (15-25), respectively. Coronary computed tomography angiography is able to rule-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-in functionally 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. Stress ECG 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 the optimal PTP range for each test and on the assumed reference standard.
Disciplines :
Cardiovascular & respiratory systems
Author, co-author :
Knuuti, Juhani
Ballo, Haitham
Juarez-Orozco, Luis Eduardo
Saraste, Antti
Kolh, Philippe ; Université de Liège - ULiège > Département des sciences biomédicales et précliniques > Biochimie et physiologie générales, humaines et path.
Rutjes, Anne Wilhelmina Saskia
Juni, Peter
Windecker, Stephan
Bax, Jeroen J.
Wijns, William
Language :
English
Title :
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.
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