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Original research article
Computed tomographic coronary angiography in risk stratification prior to non-cardiac surgery: a systematic review and meta-analysis
  1. Anoop N Koshy1,2,3,
  2. Francis Jonathan Ha1,
  3. Paul J Gow2,3,
  4. Hui-Chen Han1,2,
  5. FM Amirul-Islam4,
  6. Han S Lim1,2,
  7. Andrew W Teh1,2,
  8. Omar Farouque1,2
  1. 1 Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
  2. 2 Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia
  3. 3 Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
  4. 4 Department of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Victoria, Australia
  1. Correspondence to A/Prof. Omar Farouque; omar.farouque{at}


Objectives Utility of CT coronary angiography (CTA) and coronary artery calcium (CAC) scoring in risk stratification prior to non-cardiac surgery is unclear. Although current guidelines recommend stress testing in intermediate-high risk individuals, over one-third of perioperative major adverse cardiovascular events (MACE) occur in patients with a negative study. This systematic review and meta-analysis evaluates the value of CTA and CAC score in preoperative risk prognostication prior to non-cardiac surgery.

Methods MEDLINE, PubMed and EMBASE databases were searched for articles published up to June 2018. Summary ORs for degree of coronary artery disease (CAD) and perioperative MACE were pooled using a random-effects model.

Results Eleven studies were included. Two hundred and fifty-two (7.2%) MACE occurred in 3480 patients. Risk of perioperative MACE rose with the severity and extent of CAD on CTA (no CAD 2.0%; non-obstructive 4.1%; obstructive single-vessel 7.1%; obstructive multivessel 23.1%, p<0.001). Multivessel disease (MVD) demonstrated the greatest risk (OR 8.9, 95% CI 5.1 to 15.3, p<0.001). Increasing CAC score was associated with higher perioperative MACE (CAC score: ≥100 OR 5.1, ≥1000 OR 10.4, both p<0.01). In a cohort deemed high risk by established clinical indices, absence of MVD on CTA demonstrated a negative predictive value of 96% (95% CI 92.8 to 98.4) for predicting freedom from MACE.

Conclusions Severity and extent of CAD on CTA conferred incremental risk for perioperative MACE in patients undergoing non-cardiac surgery. The ‘rule-out’ capability of CTA is comparable to other non-invasive imaging modalities and offers a viable alternative for risk stratification of patients undergoing non-cardiac surgery.

Trial registration number CRD42018100883

  • CT
  • coronary angiography
  • non-cardiac surgery
  • preoperative
  • postoperative complications

Statistics from


  • Contributors ANK and FJH conducted data acquisition and analysis and drafted the manuscript. H-CH, AWT, HSL, FMA-I, PJG and OF supervised study design, data interpretation and assisted with drafting and reviewing of manuscript.

  • Funding ANK is a recipient of the National Health and Medical Research Council of Australia/National Heart Foundation Post-Graduate Scholarship and Royal Australasian College of Physicians Blackburn Scholarship. AWT is a recipient of the Early Career Fellowship from the National Health and Medical Research Council of Australia. HSL is supported by the Neil Hamilton Fairley Early Career Fellowship from the National Health and Medical Research Council of Australia.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.

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