Coronary computed tomography angiography vs stress testing for stable angina evaluation: Diagnostic and prognostic superiority

Abstract

BACKGROUND

Stable angina pectoris, a clinical manifestation of coronary artery disease (CAD), is commonly evaluated using non-invasive diagnostic tools. Traditionally, stress testing modalities such as exercise electrocardiography (ECG), myocardial perfusion imaging (MPI), and stress echocardiography have been the first-line strategies. However, coronary computed tomography angiography (CCTA), an anatomic imaging modality, is increasingly used for its ability to directly visualize coronary artery stenoses and plaque burden. Despite growing adoption, the comparative effectiveness of CCTA and stress testing in terms of diagnostic accuracy, prognostic value, and clinical outcomes in stable angina remains an area of active debate.

AIM

To compare the diagnostic and prognostic performance of CCTA with various forms of stress testing in adult patients presenting with suspected or confirmed stable angina.

METHODS

A comprehensive literature search was performed across PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials in accordance with the PRISMA guidelines. Only randomized controlled trials (RCT) published in English within the last 15 years were included. Studies involving adult patients (≥ 18 years) with stable angina or low-risk chest pain were selected. The intervention was CCTA, and the comparators included ECG, MPI, and stress echocardiography. Data were extracted using a standardized process, and study quality was assessed using the Cochrane Risk of Bias 2.0 tool. Due to heterogeneity in outcome measures and modalities, narrative synthesis was employed.

RESULTS

Five high-quality RCTs encompassing a total of 5551 patients were included. CCTA demonstrated superior diagnostic accuracy and prognostic capability across multiple studies. It was more effective in predicting major adverse cardiac events, including myocardial infarction and cardiac death, and was associated with fewer unnecessary invasive coronary angiographies and better event-free survival. Studies also reported improved revascularization rates in patients evaluated with CCTA, particularly within tiered diagnostic protocols. Stress testing, while useful, showed limitations in sensitivity and downstream clinical decision-making.

CONCLUSION

CCTA offers a diagnostically superior and clinically impactful strategy for the initial evaluation of patients with stable angina, especially those with intermediate pretest probability of CAD. Compared to conventional stress testing, it enhances risk stratification, reduces unnecessary procedures, and may improve long-term outcomes. These findings support its broader integration into diagnostic pathways for stable angina.

Keywords: Coronary computed tomography angiography; Stable angina; Stress testing; Myocardial perfusion imaging; Diagnostic accuracy; Prognostic evaluation; Event-free survival; Non-invasive cardiac imaging; Revascularization; Coronary artery disease

Core Tip: This systematic review compares coronary computed tomography angiography (CCTA) and stress testing in patients with stable angina. Analyzing five randomized controlled trials, the study highlights the superior diagnostic accuracy and prognostic value of CCTA. CCTA was associated with fewer unnecessary invasive procedures, better event-free survival, and more appropriate revascularization decisions compared to stress testing modalities. These findings support the integration of CCTA into first-line diagnostic pathways for intermediate-risk patients, promoting earlier diagnosis and optimized patient management.