A new integrated clinical-biohumoral model to predict functionally significant coronary artery disease in patients with chronic chest pain

Background - The choice of imaging techniques in patients with suspected coronary artery disease (CAD) varies between countries, regions and hospitals. This prospective, multi-centre, comparative effectiveness study was designed to assess the relative accuracy of commonly used imaging techniques for identifying patients with significant CAD. Methods and Results A total of 475 patients with stable chest pain and intermediate likelihood of CAD underwent coronary computed tomographic angiography (CCTA) and stress myocardial perfusion imaging (MPI) by single photon emission computed tomography or positron emission tomography, and/or ventricular wall motion imaging (WMI) by stress echocardiography or cardiac magnetic resonance. If at least one test was abnormal, patients underwent invasive coronary angiography (ICA). Significant CAD was defined by ICA as >50% stenosis of the left main stem, >70% stenosis in a major coronary vessel, or 30-70% stenosis with .8. Significant CAD was present in 29% of patients. In a patient-based analysis CCTA had the highest diagnostic accuracy, the area under the receiver operating characteristics curve (AUC) being 0.91 (95% CI 0.88-0.94), sensitivity 91%, specificity 92%. MPI had good diagnostic accuracy (AUC 0.74, CI 0.69- 0.78), sensitivity 74%, specificity 73%. WMI had similar accuracy (AUC 0.70, CI 0.65-0.75) but lower sensitivity (49%, P<0.001) and higher specificity (92%, P<0.001). The diagnostic accuracy of MPI and WMI were lower than CCTA (P<0.001). Conclusions - In a multi-centre European population of patients with stable chest pain and low prevalence of CAD, CCTA is more accurate than non-invasive functional testing for detecting significant CAD defined invasively.