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Diagnostic accuracy and utility of coronary CT angiography with consideration of unevaluable results: A systematic review and multivariate Bayesian random-effects meta-analysis with intention to diagnose

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Abstract

Objectives

To meta-analyze diagnostic accuracy, test yield and utility of coronary computed tomography angiography (CCTA) in coronary artery disease (CAD) by an intention-to-diagnose approach with inclusion of unevaluable results.

Methods

Four databases were searched from 1/2005 to 3/2013 for prospective studies that used 16–320-row or dual-source CTs and provided 3 × 2 patient-level data of CCTA (positive, negative, or unevaluable) versus catheter angiography (positive or negative) for diagnosing ≥50 % coronary stenoses. A Bayesian multivariate 3 × 2 random-effects meta-analysis considered unevaluable CCTAs.

Results

Thirty studies (3422 patients) were included. Compared to 16–40 row CT, test yield and accuracy of CCTA has significantly increased with ≥64-row CT (P < 0.05). In ≥64-row CT, about 2.5 % (95 %-CI, 0.9–4.8 %) of diseased patients and 7.5 % (4.5–11.2 %) of non-diseased patients had unevaluable CCTAs. A positive likelihood ratio of 8.9 (6.1–13.5) indicated moderate suitability for identifying CAD. A negative likelihood ratio of 0.022 (0.01–0.04) indicated excellent suitability for excluding CAD. Unevaluable CCTAs had an equivocal likelihood ratio of 0.42 (0.22–0.71). In the utility analysis, CCTA was useful at intermediate pre-test probabilities (16–70 %).

Conclusions

CCTA is useful at intermediate CAD pre-test probabilities. Positive CCTAs require verification to confirm CAD, unevaluable CCTAs require alternative diagnostics, and negative CCTAs exclude obstructive CAD with high certainty.

Key Points

• This 3 × 2 Bayesian meta-analysis included unevaluable CCTAs with intention-to-diagnose.

• CCTA is currently useful at intermediate CAD pre-test probabilities.

• Unevaluable CCTAs should not, generally, be treated as if they are positive.

• Positive CCTAs require verification by other methods to confirm CAD.

• Negative CCTAs exclude CAD with high certainty.

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Notes

  1. * In this text “probability for CAD” means a patient’s chance for having at least one ≥50 % coronary stenosis at catheter angiography (the reference standard). “Pre-test probability” is the chance before CCTA (the index test), and “post-test probability” is the chance when knowing the CCTA results.

Abbreviations

CAD:

coronary artery disease

CT:

computed tomography

CCTA:

coronary computed tomography angiography

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Acknowledgments

The scientific guarantor of this publication is Jan Menke. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. One of the authors has significant statistical expertise. Institutional review board approval was not required because this is a meta-analysis. Study subjects or cohorts have been previously reported in the primary studies that were meta-analysed. Methodology: meta-analysis of prospective studies.

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Authors and Affiliations

  1. Institute for Diagnostic and Interventional Radiology, University Medical Center Goettingen, Robert-Koch-Strasse 40, 37075, Goettingen, Germany

    Jan Menke

  2. Department of Cardiology, Dr. Lauterbach-Klinik, Heinrich-Mann-Strasse 5, 36448, Bad Liebenstein, Germany

    Jörg Kowalski

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  1. Jan Menke
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  2. Jörg Kowalski
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Correspondence to Jan Menke.

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Menke, J., Kowalski, J. Diagnostic accuracy and utility of coronary CT angiography with consideration of unevaluable results: A systematic review and multivariate Bayesian random-effects meta-analysis with intention to diagnose. Eur Radiol 26, 451–458 (2016). https://doi.org/10.1007/s00330-015-3831-z

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  • DOI: https://doi.org/10.1007/s00330-015-3831-z

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