Coronary CTA Should Be the Initial Test in Most Patients With Stable Chest Pain: PRO

The evaluation of adults with stable chest pain concerning for possible coronary artery disease (CAD) is one of the most commonplace and costly evaluations in all of medicine. Given the number of available, well-studied, and prognostically useful noninvasive tests for CAD, there remains much debate over optimal evaluation pathways to improve clinical and cost outcomes in patients with chest pain. Current US stable ischemic heart disease guidelines favor noninvasive functional testing for myocardial ischemia in most patients, reserving anatomic testing using coronary computed tomography angiography (CTA) for patients without established CAD who have already undergone functional testing (inconclusive results or ongoing symptoms) or are unable to undergo functional testing.¹However, coronary CTA has undergone remarkable technological advancements in safety and image quality that, when paired with results from recent comparative effectiveness trials, has led many to conclude that it should be more broadly performed and serve as the first test in many patients with stable chest pain.² For example, in 2016, the National Institute for Health and Care Excellence (NICE), the evidence-based organization that guides healthcare in the United Kingdom, updated its chest pain guideline and made coronary CTA the first test for all patients without established CAD who present with typical or atypical angina or with non-anginal chest pain plus an abnormal resting electrocardiogram (ECG).³Stress imaging studies were recommended in patients with known CAD, and exercise stress ECG testing was not recommended for the diagnosis of CAD due to its low accuracy and high rates of subsequent testing. It was estimated that broad adoption of this strategy would save the UK National Health Service £16 million annually.

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