Literatuuranalyse uitgevoerd door de NICE richtlijn (2016)

In this guideline, a systematic review of the literature was performed to answer the following question:

In people with stable chest pain of suspected cardiac origin, what is the accuracy, clinical

utility and cost effectiveness of:

  1. non-invasive diagnostic tests;
  2. invasive diagnostic tests;
  3. calcium scoring?

 

P: adults presenting with stable chest pain/discomfort of recent onset of suspected cardiac origin;

I: anatomic tests (stenosis/vessel flow );

  1. Coronary angiography.
  2. CT (minimum 64-slice CT)(Coronary angiography (CTCA) / Coronary computed tomographic angiography (CCTA), multi-slice CT (MSCT), new generation cardiac computed tomography (NGCCT)).
  3. Calcium scoring (minimum 64-slice CT) Functional Tests (myocardial ischemia/wall motion)
  4. Stress echocardiography (a = Perfusion and b= Wall motion.
  5. Stress magnetic resonance imaging (MRI) (Stress Cardiac MR (CMR) for wall motion).
  6. Stress MRI (Stress CMR) for perfusion imaging.
  7. Myocardial perfusion scintigraphy (MPS) using positron emission tomography (PET) or SPECT (single photon emission computed tomography).
  8. CT Fractional flow reserve CTFFR.
  9. CT myocardial perfusion.
  10. Positron emission tomography (PET) scan.

C/R: coronary angiography (at all percentage stenosis levels, reported separately to include 50% and 70% stenosis);

O: Diagnostic accuracy measurements (for example sensitivity, specificity, likelihood ratios), CAD, adverse events/side effects.

 

Relevant outcome measures

The guideline development group considered CAD as a critical outcome measure for decision making; and true positive, false positive, false negative, true negative, sensitivity and specificity as an important outcome measure for decision making.

 

The working group did not define a minimum acceptability threshold for either sensitivity or specificity for any test. In terms of incorrect diagnoses, the working group agreed that the consequences of a false negative result (possible cardiac event or death) were likely to be more serious for the patient and the healthcare system than a false positive result.

 

Search and select (Methods)

For de NICE guideline, the databases Medline, Embase, and Cochrane were searched with relevant search terms until 10 May 2016. The detailed search strategy is depicted under the tab Methods.

Studies were selected based on the following criteria:

 

The systematic literature search resulted in 10,637 hits. 749 studies were initially selected based on title and abstract screening. An additional 3 articles were identified from the existing guideline which were not retrieved in the searches. After reading the full text, 693 studies were excluded (see the table with reasons for exclusion under the tab Methods), and 60 studies were included.

 

In the course of development, a supplementary narrative review was conducted to identify test and treat randomized controlled trials that included one of more of the index tests identified in the main diagnostic test accuracy review.

 

The search identified 9200 records. Of these 995 were articles that were also identified in the main diagnostic test accuracy review, and so were not examined further, and 8194 were excluded on the basis of title and abstract. Eleven full text articles were examined and 8 were excluded, leaving 3 included studies. Details of the included studies were extracted into evidence tables, and narrative summaries are provided below.

 

Results

60 studies were included in the analysis of the literature. Important study characteristics and results are summarized in the evidence tables. The assessment of the risk of bias is summarized in the risk of bias tables.

 

Summary of literature

Description of studies - questions 2 &3

Sixty cross-sectional, diagnostic studies were included, with a total of 9,780 participants. A summary of key characteristics of each study are shown in Table 1. Population was classified as one of the following 4 categories:

A Population had suspected coronary artery disease (CAD), but there was no breakdown of numbers with chest pain, or the numbers with chest pain was less than 50%.

B Population had suspected CAD and 50% or more had chest pain.

C All participants had suspected CAD and chest pain (combination of types e.g. typical angina, atypical angina, non-cardiac).

D All participants had suspected CAD and typical chest pain of suspected cardiac origin.

 

Table 1 Summary of included studies

Study (author/year)

Total sample size

Age

Mean (SD)

Study population category

Index test (a)

Location

Arnold, 2010

65

64 (9)

A: Suspected CAD

4a, 4b, 4a+4b

Unclear (?UK, Australia, Poland)

Bettencourt, 2011

90

62 (8)

B: Suspected CAD, 92% with chest pain

2,9, 2+9

Portugal

Budoff, 1998

33

55 (9)

C: 100% with chest pain (combination of types)

7

USA

Budoff, 2007

30

54 (9)

A: Suspected CAD

7

USA

Budoff, 2008

230

57 (10)

C: 100% with chest pain (combination of types)

2

USA

Budoff, 2013

230

57 (10)

C: 100% with chest pain (combination of types)

3

USA

Cademartiri, 2007

72

54 (8)

C: 100% with chest pain (combination of types)

2

Italy

Cademartiri, 2008

145

63 (10)

B: Suspected CAD, 81% with chest pain

2

Italy

Carrascosa, 2010

50

62 (13)

B: Suspected CAD, 82% with chest pain

2

Argentina

Chen, 2011

113

62 (SD

not reported)

C: 100% with chest pain (combination of types)

2

Taiwan

Cramer, 1997

78

58 (SD

not reported)

D: 100% stable chest pain of suspected cardiac origin

7

The Netherlands

Di Bello, 1996a

45

53 (7)

C: 100% with chest pain (combination of types)

4b,7

Italy

Di Bello, 1996b

45

53 (7)

C: 100% with chest pain (combination of types)

4b,7

Italy

Donati, 2010

52

64 (10)

C: 100% with chest pain (combination of types)

2

Switzerland/USA (unclear)

Fleming, 1992

44

57 (11)

A: Suspected CAD

7

USA

Fujitaka, 2009

125

70 (11)

C: 100% with chest pain

(combination of types)

2, 2+7

Japan

Hennessy, 1998

157

59 (11)

C: 100% with chest pain (combination of types)

4b

UK

Herzog, 2007

40

61 (8)

A: Suspected CAD

2

USA

Herzog, 2008

30

59 (10)

B: Suspected CAD, 63% with chest pain

2

Switzerland

Herzog, 2009

42

62 (8)

B: Suspected CAD, 62% with chest pain

2

Switzerland

Hoffmann, 1993

66

57 (10)

A: Suspected CAD

4b

Germany

Javadrashid, 2009

158

58 (10)

A: Suspected CAD

3

Iran

Kaminek, 2015

164

61 (12)

A: Suspected CAD

7

Czech Rep.

Kawase, 2004

50

67 (12)

A: Suspected CAD

6

Japan

Klein, 2008

54

60 (10)

B: Suspected CAD, 83% with chest pain

6

Germany

Klem, 2006

92

58 (12)

A: Suspected CAD

6

USA

Krittayaphong, 2009

66

61 (12)

B: Suspected CAD, 52% with chest pain

6

Thailand

Marangelli, 1994

82

68 (8)

C: 100% with chest pain (combination of types)

4b

Italy

Marwick, 1993

217

58 (10)

B: Suspected CAD, >=65% with chest pain

4b,7

Belgium

Mazeika, 1992

55

55 (9)

A: Suspected CAD

4b

UK

Meng, 2009

109

63 (9)

A: Suspected CAD

2

China

Miszalaski-Jamka, 2012

61

57 (12)

A: Suspected CAD

4a

Poland

Muhlenbruch, 2007

51

59 (8)

A: Suspected CAD

2

Germany

Nagel, 1999

208

60 (9)

A: Suspected CAD

4b, 5

Germany

Nazeri, 2009

168

58 (11)

A: Suspected CAD

2

Iran

Nieman, 2009

98

56 (10)

C: 100% with chest pain (combination of types)

2

Holland

Nixdorff, 2008

71

62 (SD

not reported)

A: Suspected CAD

4b

Unclear (Europe)

Onishi, 2010

59

64 (11)

A: Suspected CAD

4a

Japan

Overhus, 2010

100

61 (9)

B: Suspected CAD, 80% with chest pain

2

Denmark

Parodi, 1999

101

55 (9)

D: 100% stable chest pain of suspected cardiac origin

4b

Italy

Piers, 2008

60

64 (SD

not reported)

A: Suspected CAD

2

The Netherlands

Pontone, 2014

91

Not reported

A: Suspected CAD

2

Italy

Pugliese,2008

204

59 (11)

A: Suspected CAD

2

The Netherlands

Raff, 2005

70

59 (11)

A: Suspected CAD

2

USA

Rixe, 2009

76

68 (9)

B: Suspected CAD, 80% with chest pain

2

Germany

Ropers, 2006

84

58 (10)

A: Suspected CAD

2

Germany

San Roman, 1996

102

64 (11)

D: 100% stable chest pain of suspected cardiac origin

4b

Spain

San Roman, 1998

102

64 (10)

D: 100% stable chest pain of suspected cardiac origin

4b,7

Spain

Santoro, 1998

60

Not reported

C: 100% with chest pain (combination of types)

4b, 7

Italy

Schepis, 2007

77

66 (9)

B: Suspected CAD, 57% with chest pain

7, 3+7

Switzerland

Senior, 2004

55

median 61 (range

47-61)

C: 100% with chest pain (combination of types)

4b, 7

UK/Germany

Severi, 1993

429

55 (4)

C: 100% with chest pain (combination of types)

4b

Italy

Shaikh, 2014

45

61 (7)

A: Suspected CAD

4b

USA

Sheikh, 2009

73

60 (9)

C: 100% with chest pain (combination of types)

2

Kuwait

Stolzmann, 2011

60

64 (10)

B: Suspected CAD, 65% with chest pain

6, 3+6

Switzerland

Swailam, 2010

30

53 (6)

C: 100% with chest pain (combination of types)

2

Egypt

Thomassen, 2013

44

66 (9)

C: 100% with chest pain (combination of types)

2,7,2+7

Denmark

Van Werkhoven, 2010

61

57 (9)

C: 100% with chest pain (combination of types)

2

The Netherlands

Von Ziegler, 2014

4,137

61 (12)

C: 100% with chest pain (combination of types)

3

Germany

Yao, 2004

73

53 (11)

A: Suspected CAD

7

China

All studies were cross-sectional diagnostic studies.

Mean/SD are rounded to whole numbers.

Index tests 2=CTCA, 3=Calcium Scoring, 4a=Stress Echo (perfusion), 4b=Stress Echo (wall motion), 5=CMR (wall motion), 6=CMR (Perfusion), 7=MPS SPECT/PET, 8=CT FFR, 9=CT Perfusion, 10=PET

All studies had invasive coronary angiography as the reference standard. Studies reporting combined analyses are indicated by (+)

 

Results

1. Diagnostic test accuracy

The results of diagnostic accuracy are depicted in table 2.

 

Table 2 Diagnostic test accuracy meta-analysis results

Index test

Sensitivity (95% CI)

Specificity (95% CI)

50% stenosis

CTCA

0.96 (0.94 to 0.97)

0.79 (0.72 to 0.84)

Calcium score – threshold:0

0.99 (0.97 to 0.99)

0.49 (0.36 to 0.63)

Calcium score – threshold:400

0.54 (0.52 to 0.57)

0.88 (0.87 to 0.88)

Stress echocardiography, Perfusion

0.84 (0.76 to 0.90)

0.79 (0.69 to 0.86)

Stress echocardiography, Wall motion – vasodilators

0.77 (0.69 to 0.83)

0.86 (0.68 to 0.95)

Stress echocardiography, Wall motion – heart rate modifiers

0.76 (0.72 to 0.79)

0.80 (0.71 to 0.88

CMR, Perfusion

0.84 (0.76 to 0.90)

0.85 (0.77 to 0.90)

MPS-SPECT

0.81 (0.74 to 0.86)

0.78 (0.70 to 0.85)

70% stenosis

CTCA

0.96 (0.88 to 0.99)

0.72 (0.55 to 0.85)

Stress echocardiography, Wall motion – vasodilators

0.64 (0.49 to 0.76)

0.90 (0.86 to 0.93)

Stress echocardiography, Wall motion – heart rate modifiers

0.75 (0.62 to 0.85

0.88 (0.79 to 0.93)

CMR Perfusion

0.93 (0.84 to 0.97)

0.81 (0.56 to 0.93)

MPS-SPECT

0.76 (0.44 to 0.93)

0.76 (0.58 to 0.88)

 

2. CAD

This outcome was not reported.

 

3. Adverse events/side effects

In addition to diagnostic data, side-effects or minor or major adverse events associated with either test were extracted and reported in the evidence tables. No studies reported stroke or death in relation to ICA or any index test. One study reported coronary artery dissection in relation to ICA (Budoff, 2008). Two studies reported a total of 4 cardiac events in relation to administration of index tests. These are:

 

4. Additional studies (Test and treat randomised controlled trials)

SCOT-HEART (SCOT-HEART investigators, 2015) 4,146 participants with stable chest pain of suspected cardiac origin were recruited from multiple chest pain clinics in Scottish hospitals between 2010 and 2014 (mean age 57.1 years, 56% male). Participants were randomized to standard diagnostic care (which included clinical assessment, calculation of cardiovascular risk, exercise electrocardiography and further testing at the discretion of the clinician) or standard care with additional CT coronary angiography (CTCA). At 6 weeks, CTCA reclassified the diagnosis of coronary heart disease in 558 (27%) patients and the diagnosis of angina due to coronary heart disease in 481 (23%) patients. This changed planned investigations (15% versus 1%) and treatments (23% versus 5%) but did not affect 6-week symptom severity or subsequent admittances to hospital for chest pain. After 1.7 years, CTCA was associated with a 38% reduction in fatal and non-fatal myocardial infarction (26 versus 42, HR 0.62, 95% CI 0.38 to 1.01).

 

PROMISE (Douglas, 2015) 10,003 participants with suspected coronary artery disease from several centers in the USA were recruited between 2010 and 2014 (mean age 60.8 years, 53% male). Participants were randomized to CTCA or functional testing (which could include exercise electrocardiography, nuclear stress testing or stress echocardiography). Over a median follow-up period of 25 months, a primary end-point event (death, myocardial infarction, hospitalisation for unstable angina, major complication of cardiovascular or diagnostic testing procedure) occurred in 164 of 4996 patients in the CTCA group (3.3%) and in 151 of 5007 (3.0%) in the functional-testing group (adjusted HR, 1.04; 95% CI, 0.83 to 1.29). CTCA was associated with fewer catheterizations showing no obstructive CAD than was functional testing (3.4% versus 4.3%).

 

CAPP trial (McKavanagh, 2015) 500 participants with stable chest pain but without known coronary artery disease were recruited from several chest pain clinics in Northern Ireland (mean age 58.4 years, 55% male). Participants were randomized to CTCA or exercise electrocardiography as the initial diagnostic investigation and followed up for 12 months. More participants in the CTCA group were diagnosed with significant CAD (128 versus 72), and more were treated both medically and surgically (136 versus 54). Fewer hospital admissions were recorded for the CTCA group than the exercise electrocardiography group. There was a significantly greater improvement in quality of life, measured by the Seattle angina questionnaire at 12 months in the CTCA group than the exercise electrocardiography group (mean difference -24.9, 95% CI -29.6 to -20.2).

 

Level of evidence of the literature

Diagnosis of coronary artery disease - 50% stenosis threshold

CMR (wall motion analysis): The level of evidence regarding the outcome measure diagnostic accuracy was not downgraded.

 

Calcium scoring at a threshold level of 400 Hounsfield units: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by one level because of applicability (bias due to indirectness).

 

Stress echocardiography (perfusion analysis): The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by one level because of applicability (bias due to indirectness).

 

Stress echocardiography (wall motion analysis) - using heart rate modification to induce stress: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by one level because of conflicting results (inconsistency).

 

CMR (perfusion analysis): The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by one level because of applicability (bias due to indirectness).

 

Combined CTCA and myocardial perfusion scintigraphy: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by one level because of number of included patients (imprecision).

 

CT perfusion: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by two levels because of applicability (bias due to indirectness); CI for sensitivity exceeds 20% range (imprecision).

 

Combined CTCA and myocardial perfusion scintigraphy: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by two levels because of applicability (bias due to indirectness); CI for sensitivity exceeds 20% range (imprecision).

 

Combined CTCA and CT perfusion: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by two levels because of applicability (bias due to indirectness); CI for sensitivity exceeds 20% range (imprecision).

 

Combined Calcium scoring and stress CMR: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by two levels because of applicability (bias due to indirectness); CI for sensitivity and specificity exceeds 20% range (imprecision).

 

Combined Calcium scoring and myocardial perfusion scintigraphy perfusion: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by two levels because of applicability (bias due to indirectness); CI for sensitivity and specificity exceeds 20% range (imprecision).

 

Combined stress echo perfusion and wall motion: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by two levels because of applicability (bias due to indirectness); CI for sensitivity and specificity exceeds 20% range (imprecision).

 

CTCA, Calcium scoring at a threshold level of 0 Hounsfield units, Stress echography (wall motion analysis) - using vasodilators to induce stress and MPS - SPECT: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by three levels because of study limitations (risk of bias), conflicting results (inconsistency), applicability (bias due to indirectness) or CI for sensitivity and specificity exceeds 20% range (imprecision).

 

Diagnosis of coronary artery disease - 70% stenosis threshold

Calcium scoring at a threshold of 0 or 400 Hounsfield units: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by one level because of applicability (bias due to indirectness).

 

Combined CTCA and CT Perfusion: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by one level because of applicability (bias due to indirectness).

 

Stress echocardiography (perfusion analysis): The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by two levels because of applicability (bias due to indirectness); CI for sensitivity and specificity exceeds 20% range (imprecision).

 

Myocardial perfusion scintigraphy (MPS - PET): The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by two levels because of applicability (bias due to indirectness); CI for specificity exceeds 20% range (imprecision).

 

CT perfusion: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by two levels because of applicability (bias due to indirectness); CI for sensitivity exceeds 20% range (imprecision).

 

Combined Stress Echo Perfusion and Wall motion: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by two levels because of applicability (bias due to indirectness); CI for specificity exceeds 20% range (imprecision).

 

CTCA, Stress echography (wall motion analysis) - using vasodilators to induce stress, Stress echography (wall motion analysis) - using heart rate modification to induce stress, CMR (perfusion analysis) and MPS - SPECT: The level of evidence regarding the outcome measure diagnostic accuracy was downgraded by three levels because of study limitations (risk of bias), conflicting results (inconsistency), applicability (bias due to indirectness) or CI for sensitivity and specificity exceeds 20% range (imprecision).

 

Conclusions

Diagnosis of coronary artery disease - 50% stenosis threshold

High

GRADE

CMR (wall motion analysis)

The sensitivity of cardiac magnetic resonance (wall motion) is 0.86 (95%CI 0.78 to 0.92) with reference invasive coronary angiography. The specificity is 0.86 (95%CI 0.75 to 0.93).

 

Sources: (Nagel, 1999)

 

Moderate GRADE

Calcium scoring at a threshold level of 400 Hounsfield units:

The sensitivity of calcium scoring (threshold: 400 Hounsfield units) is probably 0.54 (95%CI 0.52 to 0.57) with reference invasive coronary angiography and the specificity probably 0.88 (95%CI 0.87 to 0.88).

 

Sources: (Budoff, 2013; von Zeigler, 2014)

 

Moderate GRADE

Stress echocardiography (perfusion analysis)

The sensitivity of stress echography (perfusion) is probably 0.84 (95%CI 0.76 to 0.90) with reference invasive coronary angiography and the specificity probably 0.79 (95%CI 0.69 to 0.86).

 

Sources: (Arnold, 2010; Miszalski-Jamka, 2012; Onishi, 2010)

 

Moderate GRADE

Stress echocardiography (wall motion analysis) – using heart rate modification to induce stress

The sensitivity of stress echography (wall motion) is probably 0.76 (95%CI 0.72 to 0.79) with reference invasive coronary angiography and the specificity probably 0.80 (95%CI 0.71 to 0.88).

 

Sources: (Di Bello, 1996a; Di Bello, 1996b; Hennessy, 1998; Marwick, 1993; Nagel, 1999; Onishi, 2010; San Roman, 1998; San Roman, 1996)

 

Moderate GRADE

CMR (perfusion analysis)

The sensitivity of cardiac magnetic resonance (perfusion) is probably 0.84 (95%CI 0.76 to 0.90) with reference invasive coronary angiography and the specificity probably 0.85 (95%CI 0.77 to 0.90).

 

Sources: (Arnold, 2010; Klein, 2008; Klem, 2006; Krittayaphong, 2009; Stolzmann, 2011)

 

Moderate GRADE

Combined CTCA and myocardial perfusion scintigraphy

The sensitivity of combined CTCA and myocardial perfusion scintigraphy is probably 0.94 (95%CI 0.84 to 0.99) with reference invasive coronary angiography and the specificity probably 0.95 (95%CI 0.87 to 0.99).

 

Sources: (Fujitaka, 2009)

 

Low

GRADE

CT perfusion

The sensitivity of CT perfusion is possible 0.54 (95%CI 0.39 to 0.69) with reference invasive coronary angiography and the specificity possible 1.00 (95%CI 0.92 to 1.00).

 

Sources: (Bettencourt, 2011)

 

Low

GRADE

Combined CTCA and Myocardial perfusion scintigraphy

The sensitivity of combined CTCA and myocardial perfusion scintigraphy is possible 0.91 (95%CI 0.71 to 0.99) with reference invasive coronary angiography and the specificity possible specificity of 1.00 (95%CI 0.85 to 1.00)

 

Sources: (Thomassen, 2013)

 

Low

GRADE

Combined CTCA and CT perfusion

The sensitivity of combined CTCA and CT perfusion is possible 0.83 (95%CI 0.70 to 0.93) with reference invasive coronary angiography and the specificity possible 0.98 (95%CI 0.87 to 1.00).

 

Sources: (Bettencourt, 2011)

 

Low

GRADE

Combined Calcium scoring and stress CMR

The sensitivity of combined calcium scoring and stress CMR is possible 0.89 (95%CI 0.74 to 0.97) with reference invasive coronary angiography and the specificity possible 0.83 (95%CI 0.63 to 0.95).

 

Sources: (Stolzmann, 2011)

 

Low

GRADE

Combined Calcium scoring and myocardial perfusion scintigraphy perfusion

The sensitivity of combined calcium scoring and SPECT is possible 0.86 (95%CI 0.71 to 0.95) with reference invasive coronary angiography and the specificity possible 0.86 (95%CI 0.70 to 0.95).

 

Sources: (Schepsis, 2007)

 

Low

GRADE

Combined stress echo perfusion and wall motion

The sensitivity of combined stress echo perfusion + wall motion is possible 0.85 (95%CI 0.71 to 0.94) with reference invasive coronary angiography and the specificity possible 0.76 (95%CI 0.53 to 0.92).

 

Sources: (Arnold, 2010)

 

Very low

GRADE

The evidence was very uncertain on the sensitivity and specificity for the following tests (with reference invasive coronary angiography):

  • CTCA.
  • Calcium scoring at a threshold level of 0 Hounsfield units
  • Stress echography (wall motion analysis) - using vasodilators to induce stress.
  • MPS - SPECT.

 

Sources: (Arnold, 2010; Bettencourt, 2011, Budoff, 1998, Budoff, 2008; Budoff, 2013;Cademartiri, 2007; Cademartiri, 2008; Carrascosa, 2010; Chen, 201; Cramer, 1997; Di Bello, 1996a; Di Bello, 1996b; Donati, 2007; Fleming, 1992; Fujitaka, 2009; Herzog, 2007; Herzog, 2008; Herzog, 2009; Kaminek, 2015; Marwick, 1993; Meng, 2009; Nazeri, 2009; Nieman, 2009; Overhus, 2010; Parodi, 1999; Piers, 2008; Pontone, 2014; Pugliese, 2008; Raff, 2005; Rixe, 2009; Ropers, 2006; San Roman, 1996; San Roman, 1998; Schepis, 2007; Senior, 2004; Sheikh, 2009; Swailam, 2010; Thomassen 2013; van Werkhoven, 2010; Yao, 2004; von Ziegler, 2014)

 

Diagnosis of coronary artery disease - 70% stenosis threshold

Moderate GRADE

Calcium scoring at a threshold of 0 Hounsfield units

The sensitivity of calcium scoring (threshold: 0 Hounsfield units) is probably 0.99 (95%CI 0.98 to 0.99) and the specificity probably 0.42 (95%CI 0.41 to 0.43).

 

Sources: (von Zeigler, 2014)

 

Moderate GRADE

Calcium scoring at a threshold of 400 Hounsfield units

The sensitivity of calcium scoring (threshold: 400 Hounsfield units) is probably 0.84 (95%CI 0.82 to 0.87) and the specificity probably 0.84 (95%CI 0.83 to 0.85).

 

Sources: (von Zeigler, 2014)

 

Moderate GRADE

Combined CTCA and CT Perfusion

The sensitivity of combined CTCA and CT perfusion is probably 0.95 (95%CI 0.82 to 0.99) and the specificity probably 0.94 (95%CI 0.84 to 0.99).

 

Sources: (Bettencourt, 2011)

 

Low

GRADE

Stress echocardiography (perfusion analysis)

The sensitivity of stress echocardiography (perfusion analysis) is possible 0.90 (95%CI 0.73 to 0.98) and the specificity possible 0.73 (95%CI 0.54 to 0.87).

 

Sources: (Arnold, 2010)

 

Low

GRADE

Myocardial perfusion scintigraphy (MPS - PET)

The sensitivity of MPS - PET perfusion is possible 0.91 (95%CI 0.71 to 0.99) and the specificity possible 0.86 (95%CI 0.65 to 0.97).

 

Sources: (Thomassen, 2013)

 

Low

GRADE

CT perfusion

The sensitivity of CT perfusion is possible 0.66 (95%CI 0.49 to 0.80) and the specificity possible 0.98 (95%CI 0.90 to 1.00).

 

Sources: (Bettencourt, 2011)

 

Low

GRADE

Combined Stress Echo Perfusion and Wall motion

The sensitivity of combined stress echo perfusion and wall motion is possible 0.97 (95%CI 0.82 to 1.00) and the specificity possible 0.64 (95%CI 0.45 to 0.80).

 

Sources: (Arnold, 2010)

 

Very low

GRADE

The evidence was very uncertain on the sensitivity and specificity for the following tests (with reference invasive coronary angiography):

  • CTCA.
  • Stress echography (wall motion analysis) - using vasodilators to induce stress.
  • Stress echography (wall motion analysis) - using heart rate modification to induce stress.
  • CMR (perfusion analysis).
  • MPS - SPECT.

 

Sources: (Arnold, 2010; Bettencourt, 2011; Budoff, 2007; Budoff, 2008; Hoffman, 1993; Kawase, 2004; Klem, 2006; Marangelli, 1994, Mazeika, 1991; Muhlenbruch, 2007; Nixdorff, 2007; Santoro, 1998; Senior, 2004; Severi, 1993; Shaikh, 2013)

 

Evidence tables and table of excluded studies

For the evidence tables and table of excluded studies, see the NICE website: https://www.nice.org.uk/guidance/cg95/evidence