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.

Key Words: 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.

INTRODUCTION

Stable angina pectoris is a common clinical manifestation of coronary artery disease (CAD), characterized by predictable chest pain resulting from myocardial ischemia during exertion or stress[1]. Accurate and timely diagnosis is essential to guide risk stratification, therapeutic decision-making, and to prevent adverse cardiovascular events. Currently, first-line evaluation strategies for stable angina rely on non-invasive functional testing such as exercise electrocardiography (ECG), which detects ST-segment changes during physical activity; myocardial perfusion imaging (MPI), which uses nuclear tracers to assess blood flow mismatch; and stress echocardiography, which evaluates regional wall motion abnormalities induced by stress[2]. These functional tests assess inducible ischemia and have long served as gatekeepers for invasive coronary angiography[3].

However, the diagnostic landscape has shifted with the advent of coronary computed tomography angiography (CCTA), a noninvasive anatomic imaging modality that directly visualizes coronary artery stenoses and plaque burden[4]. Multiple randomized controlled trials (RCT) have suggested that CCTA not only improves diagnostic certainty but may also enhance clinical outcomes through early implementation of preventive therapies. Furthermore, the incorporation of CCTA into initial diagnostic algorithms has been associated with reduced rates of myocardial infarction (MI) and improved efficiency in care pathways[5].

Despite its growing use, the comparative effectiveness of CCTA vs stress testing in patients with stable angina remains a subject of ongoing debate. While some studies support the superior diagnostic yield and prognostic value of CCTA, others highlight concerns about radiation exposure, cost, and overdiagnosis[6]. The interpretation of "intermediate-risk" or "low-risk" chest pain varies across guidelines, with some using the Diamond-Forrester model, while others incorporate the CAD Consortium Clinical Score or guideline-based pre-test probability estimates. This uncertainty necessitates a comprehensive evaluation of current evidence to guide clinicians in selecting the optimal initial testing strategy for stable angina[7].

Previous reviews have compared CCTA and stress testing for stable angina; however, many included heterogeneous study types and lacked focus on high-quality RCTs published in the past decade. Our review builds upon the existing literature by exclusively analyzing recent RCTs with robust methodologies, focusing on downstream clinical outcomes, and proposing future integration of advanced CCTA metrics for better risk stratification.

The objective of this systematic review is to evaluate and compare the diagnostic performance, prognostic value, and clinical outcomes associated with CCTA vs stress testing in patients with stable angina. This analysis is guided by the PICO framework[8], which defines the population as adults with suspected or confirmed stable angina; the intervention as CCTA; and the comparator as stress testing modalities, including ECG, MPI, or stress echocardiography. The outcomes of interest include diagnostic accuracy, downstream testing requirements, major adverse cardiovascular events such as MI and death, as well as patient-centered measures like quality of life and cost-effectiveness.

MATERIALS AND METHODS

Search strategy

A comprehensive literature search was conducted in accordance with the PRISMA guidelines[9] to ensure methodological rigor and transparency. Databases including PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched for RCTs comparing CCTA with various forms of stress testing-including ECG, MPI, and stress echocardiography-in adult patients with suspected or confirmed stable angina. The search strategy was developed using a combination of Medical Subject Headings (MeSH) and relevant keywords, with filters applied to include studies published in English within the past 15 years. Reference lists of relevant articles were also manually screened to capture any additional eligible studies. This approach yielded a final selection of five high-quality RCTs for evidence synthesis, each of which underwent detailed quality assessment using the Cochrane Risk of Bias 2.0 tool[10].

Eligibility criteria

Studies were selected based on predefined eligibility criteria guided by the PICO framework. The population included adult patients (≥ 18 years) with suspected or confirmed stable angina or equivalent low-risk chest pain. The intervention was diagnostic assessment using CCTA, either as a standalone modality or part of a tiered protocol. The comparator was any form of stress testing, including ECG, MPI, or stress echocardiography. The primary outcomes of interest were diagnostic accuracy, prognostic performance (e.g., prediction of MI or death), downstream testing, rates of revascularization, and other clinical endpoints such as event-free survival. Only RCTs published in English and reporting original outcome data were included. Studies focused on acute coronary syndromes, case reports, editorials, observational studies, or non-randomized trials were excluded. Risk stratification varied slightly among the included studies; however, most defined "intermediate-risk" populations based on pretest probability estimates using clinical scoring systems such as the Diamond-Forrester model or modified Duke criteria, while "low-risk" patients typically presented with atypical chest pain and minimal risk factors. These classifications were either explicitly reported or inferred based on study inclusion protocols and baseline characteristics.

Data extraction

A structured data extraction process was employed to ensure consistency and accuracy across included studies. Two independent reviewers screened titles, abstracts, and full texts to determine eligibility. For each study, key variables were extracted into a standardized table, including study design, sample size, population characteristics, type of intervention and comparator, outcomes measured, key findings, and duration of follow-up. Where necessary, discrepancies in extracted data were resolved through discussion or consultation with a third reviewer. In addition, each study underwent independent quality assessment using the Cochrane Risk of Bias 2.0 tool, evaluating randomization, outcome measurement, missing data, and reporting bias.

Data analysis and synthesis

Given the heterogeneity in comparator modalities, outcome measures, and follow-up durations, a narrative synthesis approach was adopted rather than a meta-analysis. Study findings were qualitatively compared based on clinical outcomes, diagnostic efficiency, and the ability to predict future cardiovascular events. Emphasis was placed on the relative strength of each modality in informing clinical decision-making and guiding management strategies. Tables were used to summarize extracted data and quality assessments, and risk ratios or hazard ratios (HR) were reported as provided in the original studies. A formal meta-analysis was not conducted due to significant variability in study designs, endpoints, follow-up durations, and comparator stress testing modalities across the included trials, which limited the feasibility of quantitative data pooling.

RESULTS

Study selection process

The study selection process followed the PRISMA 2009 guidelines and is illustrated in Figure 1. A total of 528 records were identified through systematic searches of four major databases: PubMed (n = 186), EMBASE (n = 152), Scopus (n = 118), and CENTRAL (n = 72). After the removal of 64 duplicate records, 464 unique records were screened based on titles and abstracts. Of these, 140 were excluded for not meeting basic relevance criteria. The remaining 324 reports were sought for full-text retrieval, but 159 could not be accessed due to availability or access issues. A total of 165 full-text articles were assessed for eligibility. Based on predefined inclusion and exclusion criteria, 160 reports were excluded for reasons such as being observational or non-randomized trials (n = 58), focusing on acute coronary syndromes (n = 34), being case reports or editorials (n = 26), lacking relevant outcomes (n = 22), non-English or duplicate publications (n = 12), or including an irrelevant population (n = 8). Ultimately, five high-quality RCTs were included in the final evidence synthesis.

Figure 1 PRISMA 2009 flow diagram illustrating the study selection process. The diagram depicts the identification, screening, and inclusion of studies based on the PRISMA guidelines. A total of 528 records were identified through four databases: PubMed (n = 186), EMBASE (n = 152), Scopus (n = 118), and Cochrane Central Register of Controlled Trials (n = 72). After removing 64 duplicates, 464 records were screened. Of these, 324 were sought for full-text retrieval, and 165 were assessed for eligibility. Ultimately, 5 randomized controlled trials were included in the final synthesis.

Characteristics of the selected studies

The characteristics of the five RCTs included in this review are summarized in Table 1. All studies evaluated adult patients with suspected or confirmed stable angina or low-risk chest pain presentations. Sample sizes ranged from 268 to 3283 participants, with populations enrolled across outpatient cardiology clinics and multi-institutional trial networks. The intervention in each study involved the use of CCTA, either as a standalone modality or integrated into a tiered diagnostic protocol, while comparators included various forms of functional stress testing such as ECG, MPI, and stress echocardiography. Across studies, outcomes assessed included diagnostic accuracy, major adverse cardiac events (MACE), event-free survival, rates of invasive angiography, revascularization indications, and healthcare utilization. Follow-up durations ranged from 6 months to 5 years, enabling both short- and long-term outcome evaluation. Overall, these trials provided robust comparative data on the diagnostic and clinical impact of CCTA vs functional testing in the stable angina population.

Table 1 Characteristics of the selected studies.

Ref.	Study design	Population characteristics	Sample size	Intervention (CCTA)	Comparator (stress testing)	Outcomes measured	Key findings	Follow-up duration
Singh et al[11]	Post hoc of RCT	Adults aged 18-75 with suspected stable angina; Scotland clinics	3283	CCTA as add-on to standard care	Exercise ECG	CHD death, nonfatal MI, diagnostic accuracy	CCTA more predictive of CHD death/MI (HR 10.63); ECG: 39% sensitivity, 91% specificity	5 years
Stillman et al[12]	Multicenter RCT	Stable angina, intermediate risk; 44 sites	1050	CCTA to guide therapy/revascularization	SPECT MPI	MACE (MI, cardiac death), revascularization	Similar outcomes (HR 1.03); CCTA better predicted MACE; fewer events in CCTA-negative patients	Mean 16.2 months
Lubbers et al[13]	Multicenter RCT	Stable angina; Dutch outpatient clinics	350	Tiered: CAC → CCTA	Functional (ECG, MPI, echo)	Event-free survival, symptoms, downstream testing, cost	Higher survival (96.7% vs 89.8%, P = 0.011); less downstream testing; lower cost	1.2 years
Lubbers et al[14]	Multicenter RCT	Stable angina; mean pretest CAD probability 54%	268	Tiered: CAC → CCTA → CT perfusion (if needed)	Functional (mostly exercise ECG)	Angiograms w/ and w/o revascularization, further testing, efficiency	Fewer unnecessary angiograms (1.5% vs 7.2%, P = 0.035); more revascularizations (88% vs 50%, P = 0.017)	6 months
Linde et al[15]	RCT	Acute chest pain with normal ECG/troponin	600	CCTA-guided; functional added if needed	Standard: Bicycle ECG or MPI	Composite: Death, MI, UAP, revascularization, readmission	Follow-up

The characteristics of the five randomized controlled trials included in this review are summarized in Table 1. These studies evaluated adult patients with suspected or confirmed stable angina or low-risk chest pain across outpatient clinics and trial networks. Interventions involved coronary computed tomography angiography, either alone or as part of a diagnostic algorithm, compared with various functional stress tests. Follow-up durations ranged from 6 months to 5 years, allowing short- and long-term assessment of outcomes including diagnostic accuracy, major adverse cardiac event, invasive angiography, and healthcare utilization. CHD: Coronary heart disease; CCTA: Coronary computed tomography angiography; RCT: Randomized controlled trial; ECG: Exercise electrocardiography; MPI: Myocardial perfusion imaging; MI: Myocardial infarction; CT: Computed tomography; CAD: Coronary artery disease; MACE: Major adverse cardiac events.

Comparative outcomes between CCTA and stress testing

To enhance clarity and facilitate direct comparison, the primary outcomes and key metrics reported in the five included RCTs are summarized in Table 2. This table presents a side-by-side evaluation of CCTA and various stress testing modalities, highlighting sample sizes, diagnostic strategies, follow-up durations, and statistical outcomes such as HRs and event rates. Across all studies, CCTA consistently demonstrated either superior or comparable performance to functional stress testing in predicting MACE, reducing unnecessary invasive procedures, and improving event-free survival. These findings reinforce the diagnostic and prognostic advantages of CCTA, particularly in intermediate-risk populations.

Table 2 Comparative outcomes between coronary computed tomography angiography and stress testing.

Ref.	Sample Size	CCTA modality	Stress test comparator	Primary outcome(s)	Hazard ratio/statistics	Follow-up duration	Key findings
Singh et al[11]	3283	CCTA as add-on to standard care	Exercise ECG	CHD death or nonfatal MI; diagnostic accuracy	HR for CHD death/MI: 10.63; ECG Sensitivity: 39%, Specificity: 91%	5 years	CCTA strongly predicted CHD events; superior diagnostic accuracy over ECG
Stillman et al[12]	1050 (CCTA: 518; SPECT: 532)	CCTA to guide therapy and revascularization	SPECT MPI	MACE (MI or cardiac death); revascularization	HR 1.03 (NS); Event rate: 1.2% (CCTA-negative) vs 3.2% (SPECT-negative)	Mean 16.2 months	CCTA better identified patients at low risk and those needing revascularization
Lubbers et al[13]	350	Tiered approach: CAC → CCTA	ECG, MPI, or Echo	Event-free survival; anginal symptoms; cost	Event-free survival: 96.7% (CCTA) vs 89.8% (Functional), P = 0.011	1.2 years	Higher event-free survival and cost-effectiveness in the CCTA group
Lubbers et al[14]	268 (CT: 130; Functional: 138)	CAC → CCTA → CT perfusion (if needed)	Mostly Exercise ECG	Angiograms (with/without revascularization); further testing	Unnecessary angiograms: 1.5% vs 7.2%, P = 0.035; Revascularization: 88% vs 50%, P = 0.017	6 months	CCTA reduced unnecessary procedures; improved selection for revascularization
Linde et al[15]	600 (CCTA: 299; Control: 301)	CCTA-guided strategy	Bicycle ECG or MPI	Composite: MI, cardiac death, UAP, revascularization, readmission	Composite events: 11% (CCTA) vs 16% (Control), HR 0.62, P = 0.04; MACE HR: 0.36	Median 18.7 months	Control

To facilitate comparison, Table 2 presents a summary of the primary outcomes and statistical metrics from the five randomized controlled trials included in this review. The table highlights the diagnostic strategies, event rates, hazard ratios, and follow-up durations. Coronary computed tomography angiography consistently showed either comparable or superior performance in predicting major adverse cardiovascular events, reducing unnecessary invasive angiography, and improving clinical outcomes compared to various stress testing methods. CHD: Coronary heart disease; CCTA: Coronary computed tomography angiography; ECG: Exercise electrocardiography; MPI: Myocardial perfusion imaging; MI: Myocardial infarction; CT: Computed tomography; MACE: Major adverse cardiac events.

Quality assessment

Quality assessment of the included studies was conducted using the Cochrane Risk of Bias 2.0 (RoB 2) tool, and the results are summarized in Table 3. All five RCTs demonstrated low risk of bias across most domains, including randomization, adherence to interventions, outcome measurement, and data completeness. Four studies were rated as having an overall low risk of bias, reflecting strong methodological quality and internal validity. One study showed some concerns in the domain of selective reporting, primarily due to a limited number of outcome events, which may affect the robustness of statistical conclusions. Nevertheless, the overall quality of evidence was high, supporting the reliability of the synthesized findings in this reviews.

Table 3 Risk of bias assessment of included studies.

Ref.	Randomization process	Deviations from intended interventions	Missing outcome data	Measurement of outcome	Selection of the reported result	Overall risk of bias
Singh et al[11]	Low	Low	Low	Low	Low	Low
Stillman et al[12]	Low	Low	Low	Low	Some concerns (limited outcome events may impact reporting)	Some concerns
Lubbers et al[13]	Low	Low	Low	Low	Low	Low
Lubbers et al[14]	Low	Low	Low	Low	Low	Low
Linde et al[15]	Low	Low	Low	Low	Low	Low

The quality of the five randomized controlled trials was assessed using the Cochrane Risk of Bias 2.0 (RoB 2) tool. As shown in Table 3, all studies were rated as having low risk of bias in randomization, adherence to interventions, outcome measurement, and completeness of outcome data. One study (RESCUE) was marked with some concerns due to limited outcome event reporting. Overall, the included studies exhibited strong methodological rigor, enhancing the reliability of this review’s conclusions.

DISCUSSION

This systematic review synthesized evidence from five high-quality RCTs to compare the clinical effectiveness of CCTA and stress testing in the evaluation of patients with suspected or confirmed stable angina. Across all studies, CCTA consistently demonstrated superior prognostic value and diagnostic efficiency. In the SCOT-HEART analysis[11], CCTA showed a markedly stronger association with the risk of coronary heart disease death or nonfatal MI, with a HR of 10.63, while exercise ECG had limited sensitivity (39%) despite high specificity (91%). Similarly, in the RESCUE trial[12], although MACE rates were statistically comparable between CCTA and SPECT arms (HR 1.03), CCTA was a better predictor of future events and associated with fewer adverse outcomes in patients with negative test results (1.2% vs 3.2%, P = 0.03).

Further supporting the diagnostic and clinical utility of CCTA, both the CRESCENT[13] and CRESCENT-II trials[14] highlighted the benefits of a tiered CCTA approach involving calcium scoring and perfusion imaging when needed. These studies reported significantly fewer unnecessary invasive angiograms (1.5% vs 7.2%, P = 0.035), faster time to diagnosis, and reduced downstream testing compared to functional modalities. In the CATCH trial[15], which included patients with acute chest pain and stable features, CCTA-guided strategy led to a significant reduction in composite clinical events (11% vs 16%, HR 0.62, P = 0.04) and MACE (HR 0.36). Collectively, these findings emphasize that CCTA is not only diagnostically robust but also clinically impactful, supporting its integration into diagnostic pathways for stable angina, in line with recent updates in clinical guidelines.

Our findings are consistent with prior large-scale studies and meta-analyses that have demonstrated the diagnostic superiority and prognostic value of CCTA in patients with suspected CAD. Landmark trials such as PROMISE[16] and SCOT-HEART have previously shown that anatomical imaging with CCTA leads to better diagnostic certainty and risk stratification compared to functional testing. However, some earlier reviews suggested that stress testing remains sufficient for lower-risk populations due to lower cost and radiation exposure. The trials included in our review bridge this gap by highlighting that in intermediate-risk and diagnostically uncertain cases, CCTA not only improves accuracy but also informs more appropriate downstream management. Variations in outcomes between studies may be attributed to differences in study populations, imaging protocols, and clinical settings.

The results of this review support a shift toward favoring CCTA as a first-line diagnostic tool in patients with suspected stable angina, particularly in those with intermediate pretest probability of CAD[17-19]. CCTA not only improves diagnostic accuracy but also reduces unnecessary downstream testing and invasive procedures, as shown in trials like CRESCENT-II[14] and CATCH[15]. Furthermore, its ability to directly visualize coronary plaque and quantify disease burden allows for more personalized and timely risk-based management[20,21].

Nonetheless, certain limitations of CCTA should be acknowledged. These include exposure to ionizing radiation, risk of contrast-induced nephropathy-particularly in patients with reduced glomerular filtration rate-and decreased diagnostic accuracy in the presence of heavy coronary calcification due to blooming artifacts. In addition, CCTA has reduced spatial resolution compared to invasive coronary angiography when evaluating small or distal vessels. Stress testing remains preferable in select populations, including patients with severe chronic kidney disease (CKD) (estimated glomerular filtration rate < 30 mL/minute/1.73 m²), contrast allergy, or those in facilities without CCTA capability. Modalities such as stress echocardiography or MPI are advantageous in these scenarios.

Limited access to CCTA, particularly in rural or resource-constrained healthcare settings, also poses a barrier to widespread adoption. Disparities in equipment availability, specialized training, and reimbursement models can hinder its routine clinical use in non-tertiary centers. From a cost perspective, CCTA may initially appear more expensive due to the need for advanced imaging infrastructure. However, several trials, including CRESCENT and SCOT-HEART, demonstrated its ability to reduce overall healthcare expenditures by minimizing unnecessary invasive procedures and repeat testing. This aligns with principles of value-based care and supports its long-term cost-effectiveness.

Emerging technologies such as fractional flow reserve derived from computed tomography (CT) and myocardial blood flow quantification offer the ability to bridge anatomical and functional assessments noninvasively. These metrics have been shown to enhance diagnostic accuracy and improve patient selection for revascularization. As integration of these tools becomes more widespread, the diagnostic value of CCTA may be further amplified[22].

In several of the included studies, diagnostic findings directly influenced management pathways. For instance, in SCOT-HEART and RESCUE, CCTA-guided strategies led to earlier initiation of preventive therapies including high-intensity statins and aspirin, while CRESCENT-II demonstrated more efficient identification of patients requiring percutaneous coronary intervention. These results suggest that improved visualization of coronary anatomy can drive more targeted and timely interventions. Stress testing may still have utility in certain populations, such as those with contraindications to contrast or where perfusion data is specifically needed. Overall, the integration of CCTA into diagnostic algorithms can enhance clinical decision-making, patient outcomes, and health system efficiency.

This review was conducted with methodological rigor, adhering closely to PRISMA guidelines and focusing exclusively on high-quality RCTs to ensure the reliability and applicability of findings. The comprehensive literature search spanned multiple databases and was designed to capture the most recent and relevant evidence, minimizing selection bias. Data extraction and quality assessment were systematically performed using validated tools such as RoB 2.0[21], which reinforced the internal validity of the included studies. The consistency of findings across diverse geographic and clinical settings further strengthens the generalizability of our conclusions.

Despite the strengths of this review, several limitations must be acknowledged. The included studies varied in terms of follow-up duration, comparator modalities (e.g., ECG, SPECT, MPI), and diagnostic thresholds, introducing some degree of heterogeneity. Some trials, such as RESCUE[12], had relatively low event rates, which may limit the statistical power to detect differences in major outcomes. Furthermore, publication bias cannot be entirely excluded, and our focus on English-language RCTs may have led to the exclusion of relevant studies. Additionally, while most studies included intermediate-risk patients, generalizability to low-risk or high-risk populations may be limited.

Future research should aim to evaluate the long-term clinical outcomes of CCTA-guided strategies beyond 5 years and in diverse patient subgroups such as diabetics, women, and patients with prior inconclusive testing. Head-to-head trials comparing CCTA with newer functional imaging modalities, including positron emission tomography and magnetic resonance imaging-based techniques, would also help clarify optimal diagnostic pathways[22]. Additionally, the role of hybrid protocols that integrate anatomical and perfusion imaging warrants further investigation. Artificial intelligence-driven platforms for CCTA interpretation and cost-effectiveness analyses across various healthcare systems may also help refine the use of CCTA in routine cardiovascular care[23].

CONCLUSION

This systematic review demonstrates that CCTA offers superior diagnostic accuracy and prognostic value compared to stress testing in patients with stable angina. It enables earlier diagnosis, better risk stratification, and reduced unnecessary testing, supporting its role as a preferred first-line tool, especially in intermediate-risk populations. However, stress testing retains value in select scenarios-such as patients with advanced CKD, contrast allergy, or limited access to CCTA-highlighting the need for individualized diagnostic strategies. Future studies should evaluate the clinical utility of CT-derived fractional flow reserve and hybrid protocols (e.g., CCTA plus perfusion) in large, diverse cohorts to further optimize care.