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

COME-CCT Consortium

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Abstract

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 Unpublished studies were identified via direct contact with participating investigators.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.

Original languageEnglish
Article numberel1945
JournalB M J
Volume365
Number of pages15
ISSN0959-8146
DOIs
Publication statusPublished - 12. Jun 2019

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Meta-Analysis
Coronary Artery Disease
Coronary Angiography
Computed Tomography Angiography
Information Storage and Retrieval
ROC Curve
Area Under Curve
Linear Models

Keywords

  • Angina Pectoris/diagnostic imaging
  • Computed Tomography Angiography/methods
  • Coronary Artery Disease/complications
  • Coronary Vessels/diagnostic imaging
  • Feasibility Studies
  • Humans
  • Predictive Value of Tests
  • Probability

Cite this

@article{24bf1f1bb4ee493cb52fa4f04f63b8f5,
title = "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",
abstract = "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.",
keywords = "Angina Pectoris/diagnostic imaging, Computed Tomography Angiography/methods, Coronary Artery Disease/complications, Coronary Vessels/diagnostic imaging, Feasibility Studies, Humans, Predictive Value of Tests, Probability",
author = "Robert Haase and Peter Schlattmann and Pascal Gueret and Daniele Andreini and Gianluca Pontone and Hatem Alkadhi and J{\"o}rg Hausleiter and Garcia, {Mario J} and Sebastian Leschka and Meijboom, {Willem B} and Elke Zimmermann and Bernhard Gerber and Schoepf, {U Joseph} and Shabestari, {Abbas A} and N{\o}rgaard, {Bjarne L} and Meijs, {Matthijs F L} and Akira Sato and Ovrehus, {Kristian A} and Diederichsen, {Axel C P} and Jenkins, {Shona M M} and Juhani Knuuti and Ashraf Hamdan and Halvorsen, {Bj{\o}rn A} and Vladimir Mendoza-Rodriguez and Rochitte, {Carlos E} and Johannes Rixe and Wan, {Yung Liang} and Christoph Langer and Nuno Bettencourt and Eugenio Martuscelli and Said Ghostine and Buechel, {Ronny R} and Konstantin Nikolaou and Hans Mickley and Lin Yang and Zhaqoi Zhang and Chen, {Marcus Y} and Halon, {David A} and Matthias Rief and Kai Sun and Beatrice Hirt-Moch and Hiroyuki Niinuma and Marcus, {Roy P} and Simone Muraglia and R{\'e}da Jakamy and Chow, {Benjamin J} and Kaufmann, {Philipp A} and Jean-Claude Tardif and Cesar Nomura and Kofoed, {Klaus F} and {COME-CCT Consortium}",
note = "Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.",
year = "2019",
month = "6",
day = "12",
doi = "10.1136/bmj.l1945",
language = "English",
volume = "365",
journal = "B M J",
issn = "0959-8146",
publisher = "BMJ Group",

}

TY - JOUR

T1 - 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

T2 - meta-analysis of individual patient data

AU - Haase, Robert

AU - Schlattmann, Peter

AU - Gueret, Pascal

AU - Andreini, Daniele

AU - Pontone, Gianluca

AU - Alkadhi, Hatem

AU - Hausleiter, Jörg

AU - Garcia, Mario J

AU - Leschka, Sebastian

AU - Meijboom, Willem B

AU - Zimmermann, Elke

AU - Gerber, Bernhard

AU - Schoepf, U Joseph

AU - Shabestari, Abbas A

AU - Nørgaard, Bjarne L

AU - Meijs, Matthijs F L

AU - Sato, Akira

AU - Ovrehus, Kristian A

AU - Diederichsen, Axel C P

AU - Jenkins, Shona M M

AU - Knuuti, Juhani

AU - Hamdan, Ashraf

AU - Halvorsen, Bjørn A

AU - Mendoza-Rodriguez, Vladimir

AU - Rochitte, Carlos E

AU - Rixe, Johannes

AU - Wan, Yung Liang

AU - Langer, Christoph

AU - Bettencourt, Nuno

AU - Martuscelli, Eugenio

AU - Ghostine, Said

AU - Buechel, Ronny R

AU - Nikolaou, Konstantin

AU - Mickley, Hans

AU - Yang, Lin

AU - Zhang, Zhaqoi

AU - Chen, Marcus Y

AU - Halon, David A

AU - Rief, Matthias

AU - Sun, Kai

AU - Hirt-Moch, Beatrice

AU - Niinuma, Hiroyuki

AU - Marcus, Roy P

AU - Muraglia, Simone

AU - Jakamy, Réda

AU - Chow, Benjamin J

AU - Kaufmann, Philipp A

AU - Tardif, Jean-Claude

AU - Nomura, Cesar

AU - Kofoed, Klaus F

AU - COME-CCT Consortium

N1 - Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

PY - 2019/6/12

Y1 - 2019/6/12

N2 - 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.

AB - 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.

KW - Angina Pectoris/diagnostic imaging

KW - Computed Tomography Angiography/methods

KW - Coronary Artery Disease/complications

KW - Coronary Vessels/diagnostic imaging

KW - Feasibility Studies

KW - Humans

KW - Predictive Value of Tests

KW - Probability

U2 - 10.1136/bmj.l1945

DO - 10.1136/bmj.l1945

M3 - Journal article

VL - 365

JO - B M J

JF - B M J

SN - 0959-8146

M1 - el1945

ER -