Efficacy of noninvasive cardiac imaging tests in diagnosis and management of stable coronary artery disease

Figures & data

Table 1 Summary of non-invasive imaging modalities for assessment of suspected stable angina

Modality	Advantages	Disadvantages	Diagnostic accuracy	Ionizing radiation dose
exECG	• Cheap • Easy to perform • Requires little post-processing/analysis • Extensive long-term data	•Relatively poor diagnostic accuracy •Limited by patient’s physical capacity	Sensitivity: 60% Specificity: 76%^Citation9	Nil
MPS/SPECT	• Extensive long-term prognostic data • FFR (current invasive gold standard) initially validated against SPECT • Can be performed with exercise, vasodilator or dobutamine stress • Offers functional information • PET/CT has potential to offer anatomical information in addition to functional ischemia assessment	• Radiation • Difficulty in the assessment of balanced ischemia • False positives in LBBB due to partial volume effects	Per vessel^Citation47 Sensitivity: 61% (vs. FFR) Specificity: 84% (vs. FFR) Per patient^Citation47 Sensitivity: 74% Specificity: 79% (vs. FFR)	7.2 mSv^Citation75
Stress echo	• Nonionizing • Extensive long-term data • Relatively fast to perform • Information on LV function and valves • Viability assessment possible with dobutamine	• Exercise limited by patient’s physical capacity • Despite use of contrast views may still be suboptimal • False positives with LBBB • Dobutamine not as physiological as exercise	Per patient^Citation47 Sensitivity: 69% Specificity: 84% (vs. FFR)	Nil
CMR	• Nonionizing • Gold standard for noninvasive assessment of ventricle mass and function • Offers viability assessment with the use of LGE imaging • Offers assessment of valves and extra-cardiac structures • Able to assess the heart in any plane	• Expensive • Expertise not yet widely available in all centers • Unable to perform in patients with claustrophobia or renal impairment (eGFR <30 mL/min) • Image quality may be degraded by arrhythmia/tachycardia, breath holding • Relatively time-consuming • MR angiography not yet at the required resolution to offer coronary angiography	Per vessel^Citation47 Sensitivity: 87% Specificity: 91% (vs. FFR) Per patient^Citation47 Sensitivity: 89% Specificity: 87% (vs. FFR)	Nil
CTCA	• Excellent anatomical detail • Particularly useful as a rule-out test due to high sensitivity and low false-negative rate • Able to offer some information on function and valves • Readily available on most modern CT scanners with minimal upgrading • Also offers extra-cardiac assessment such as “triple rule-out” test	• Radiation (although if optimal is equivalent invasive coronary angiogram) • No ventricular functional assessment unless retrospective gating is used with a consequent increase in radiation dose • Techniques to provide functional assessment of ischemia are not yet ready for routine clinical use (CT perfusion, FFR-CT) • Image quality very dependent on optimization of patient factors (heart rate/rhythm, breath holding) • Caution in patients with renal impairment	Per vessel^Citation76 Sensitivity: 91% Specificity: 58% (vs. FFR) Per patient^Citation76 Sensitivity: 90% Specificity: 39% (vs. FFR)	1–3 mSv^Citation56,Citation78

Note: Median ionizing radiation dose for invasive coronary angiography is 7.4 mSv.⁷⁸

Abbreviations: CMR, cardiovascular magnetic resonance; CT, computed tomography; CTCA, CT coronary angiography; exECG, exercise echocardiography; eGFR, estimated glomerular filtration rate; FFR, fractional flow reserve; LBBB, left bundle branch block; LGE, late gadolinium enhancement; LV, left ventricular; MPS, myocardial perfusion scintigraphy; MR, magnetic resonance; PET, positron emission tomography; SPECT, single-photon emission computed tomography.

Figure 1 Proposed investigation algorithm for patients with suspected angina focusing on patients with low or high PTP of CAD.

Abbreviations: CAD, coronary artery disease; CTCA, computed tomography coronary angiography; ECG, echocardiography; ICA, invasive coronary angiography; PTP, pretest probability.

Figure 2 Proposed investigation algorithm for patients with suspected angina and intermediate probability of CAD in an “ideal” hospital with all modalities available.

Abbreviations: CAD, coronary artery disease; CTCA, computed tomography coronary angiography; CTFFR, computed tomography fractional flow reserve; CMR, cardiovascular magnetic resonance; ECG, electrocardiogram; exECG, exercise ECG; SPECT, single-photon emission computed tomography.

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