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

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.

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.

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.