Use of CT coronary angiography (CTCA) to evaluate chest pain has rapidly increased over the recent years. While its utility in the diagnosis of coronary artery disease in stable chest pain syndromes is clear and is strongly endorsed by international guidelines, the role of CTCA in the acute setting is less certain. In the low-risk setting, CTCA has been shown to be accurate, safe and efficient but inherent low rates of adverse events in this population and the advent of high-sensitivity troponin testing have left little room for CTCA to show any short-term clinical benefit.
In higher-risk populations, CTCA has potential to fulfil a gatekeeper role to invasive angiography. The high negative predictive value of CTCA is maintained while also identifying non-obstructive coronary disease and alternative diagnoses in the substantial group of patients presenting with chest pain who do not have type 1 myocardial infarction. For those with obstructive coronary disease, CTCA provides accurate assessment of stenosis severity, characterisation of high-risk plaque and findings associated with perivascular inflammation. This may allow more appropriate selection of patients to proceed to invasive management with no disadvantage in outcomes and can provide a more comprehensive risk stratification to guide both acute and long-term management than routine invasive angiography.
- computed tomography angiography
- coronary angiography
- acute coronary syndrome
- delivery of health care
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Contributors CG, MCW, DEN and PDA conceived, wrote, revised and approved the manuscript.
Funding CG is supported by the Heart Foundation of New Zealand (1899) and the Health Research Council of New Zealand (22/108). MCW is supported by the British Heart Foundation (FS/ICRF/20/26002). DEN is supported by the British Heart Foundation (CH/09/002, RG/16/10/32375, RE/18/5/34216) and is the recipient of a Wellcome Trust Senior Investigator Award (WT103782AIA). PDA is supported by Heart Foundation of New Zealand Senior Fellowship (1844).
Competing interests PDA, DEN and MCW are editorial board members of Heart.
Provenance and peer review Commissioned; externally peer reviewed.