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
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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. / Haase, Robert; Schlattmann, Peter; Gueret, Pascal; Andreini, Daniele; Pontone, Gianluca; Alkadhi, Hatem; Hausleiter, Jörg; Garcia, Mario J.; Leschka, Sebastian; Meijboom, Willem B.; Zimmermann, Elke; Gerber, Bernhard; Schoepf, U. Joseph; Shabestari, Abbas A.; Nørgaard, Bjarne L.; Meijs, Matthijs F.L.; Sato, Akira; Ovrehus, Kristian A.; Diederichsen, Axel C.P.; Jenkins, Shona M.M.; Knuuti, Juhani; Hamdan, Ashraf; Halvorsen, Bjørn A.; Mendoza-Rodriguez, Vladimir; Rochitte, Carlos E.; Rixe, Johannes; Wan, Yung Liang; Langer, Christoph; Bettencourt, Nuno; Martuscelli, Eugenio; Ghostine, Said; Buechel, Ronny R.; Nikolaou, Konstantin; Mickley, Hans; Yang, Lin; Zhang, Zhaqoi; Chen, Marcus Y.; Halon, David A.; Rief, Matthias; Sun, Kai; Hirt-Moch, Beatrice; Niinuma, Hiroyuki; Marcus, Roy P.; Muraglia, Simone; Jakamy, Réda; Chow, Benjamin J.; Kaufmann, Philipp A.; Tardif, Jean Claude; Nomura, Cesar; Kofoed, Klaus F.; Laissy, Jean Pierre; Arbab-Zadeh, Armin; Kitagawa, Kakuya; Laham, Roger; Jinzaki, Masahiro; Hoe, John; Rybicki, Frank J.; Scholte, Arthur; Paul, Narinder; Tan, Swee Y.; Yoshioka, Kunihiro; Röhle, Robert; Schuetz, Georg M.; Schueler, Sabine; Coenen, Maria H.; Wieske, Viktoria; Achenbach, Stephan; Budoff, Matthew J.; Laule, Michael; Newby, David E.; Dewey, Marc.
In: The BMJ, Vol. 365, el1945, 06.2019.Research output: Contribution to journal › Journal article › Research › peer-review
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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 - Laissy, Jean Pierre
AU - Arbab-Zadeh, Armin
AU - Kitagawa, Kakuya
AU - Laham, Roger
AU - Jinzaki, Masahiro
AU - Hoe, John
AU - Rybicki, Frank J.
AU - Scholte, Arthur
AU - Paul, Narinder
AU - Tan, Swee Y.
AU - Yoshioka, Kunihiro
AU - Röhle, Robert
AU - Schuetz, Georg M.
AU - Schueler, Sabine
AU - Coenen, Maria H.
AU - Wieske, Viktoria
AU - Achenbach, Stephan
AU - Budoff, Matthew J.
AU - Laule, Michael
AU - Newby, David E.
AU - Dewey, Marc
PY - 2019/6
Y1 - 2019/6
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.
U2 - 10.1136/bmj.l1945
DO - 10.1136/bmj.l1945
M3 - Journal article
C2 - 31189617
AN - SCOPUS:85067274664
VL - 365
JO - The BMJ
JF - The BMJ
SN - 0959-8146
M1 - el1945
ER -
ID: 240736161