In a healthcare environment relying on evidence-based medicine and cost-effectiveness, patient outcome and prognosis should be the final and main step in the evaluation process of any newly installed diagnostic technique. In this sense, an increasing number of ongoing studies are being developed to determine the prognostic value of CCTA in symptomatic patients with chest pain and suspected or known CAD. After a mean follow-up of 78 months of a cohort of 2538 consecutive patients who underwent CCTA by electron beam CT, Ostrom et al68 observed that the burden of angiographic disease detected by CCTA provided both independent and incremental value in predicting all-cause mortality in symptomatic patients independent of age, sex, conventional risk factors, and coronary artery calcification. Min et al69 analyzed the association between extent and severity of CAD defined by CCTA and all-cause death in a consecutive cohort of 1127 symptomatic patients 45 years of age or older with similar results. These investigators concluded that CCTA could identify increased risk for all-cause death, whereas a negative CCTA study showed an extremely low risk for death. Hence, in symptomatic individuals with an intermediate likelihood of CAD referred for CCTA, normal coronary arteries or nonobstructive CAD carries an excellent prognosis, whereas the finding of obstructive CAD identifies patients at a higher risk of subsequent myocardial infarction.70–72 In line with this, diverse follow-up studies also reveal that CCTA safely rules out CAD in patients with suspected disease,73,74 effectively triaging symptomatic patients for conventional coronary angiography. From a slightly different point of view, Hadamitzky et al75 compared the observed rate of all cardiac events with the event rate predicted by the Framingham risk score in 1256 consecutive patients with suspected CAD who underwent 64-row CCTA during the 18-month follow-up period. Interestingly, these investigators observed that in their patient population, the rate of all cardiac events in patients without obstructive CAD was significantly lower than predicted by the Framingham risk score. Thus, all these studies agree that there is evidence that the extent and severity of CAD defined at CCTA predicts all-cause mortality, whereas patients with a normal CCTA have an excellent prognosis (Fig. 7).
After almost 2 decades of feasibility testing, cost-effectiveness results of CCTA with respect to clinically established diagnostic modalities are now becoming available. Initial reports suggested that CCTA is the most cost-effective approach for individuals with low and intermediate pretest likelihood of CAD, whereas for patients with a pretest probability of CAD greater than 60%, conventional coronary angiography remains more cost-effective.76 In a recent systematic review, Mowatt et al77 analyzed the clinical effectiveness and cost-effectiveness of 64-row or higher CCTA as an alternative to conventional catheterization in the CAD scenario and concluded that in this clinical setting, 64-row CCTA seems to be superior to myocardial perfusion scintigraphy. In terms of cost, these investigators described CCTA to be a short-term and probably a long-term cost-effective replacement for myocardial perfusion scintigraphy in diagnosing CAD.77 A negative CCTA for CAD should avoid the costs of unnecessary catheterizations, thus resulting in overall cost savings in the diagnostic process of CAD.
As discussed, particularly when performed with the newest technology, CCTA provides accurate and reliable information regarding CAD. This technique allows noninvasive assessment of the extent of CAD. The cornerstone of CCTA is based, however, on its high negative predictive value, which allows for significant coronary artery stenosis to be ruled out in the majority of individuals. Limitations regarding insufficient spatial and temporal resolution of the MDCT scanners may cause false-positive findings, directly influencing patient management. Thus, CCTA should be used in the appropriate clinical scenario and should be prevented from indiscriminate use to invigorate its adequate role in the diagnostic workup of patients with suspicion of CAD. Because CCTA has so far been an anatomic modality, it hardly provides information about the functional significance of stenosis severity. The presence of significant coronary artery stenosis does not necessarily translate into myocardial ischemia,78 a fact that supports the need for diagnostic tools that combine morphologic and functional information. Furthermore, because CCTA provides a significant amount of information that was not readily available before the development of CCTA, such as coronary artery plaque composition or detection of significant coronary artery stenosis in individuals with noncardiac origin atypical chest pain, determination of the prognostic significance of these findings requires further research. Finally, CCTA may serve as guidance for percutaneous interventional procedures, as this noninvasive technique may influence the decision-making of individuals who may benefit from percutaneous therapy or rather undergo elective bypass surgery.79,80
The availability, ease of use, and accuracy of CCTA has substantially improved in the last decade. This technique has shown its usefulness in a number of clinical scenarios in individuals with known or suspected CAD. Particularly, its ability to confidently rule out significant coronary artery stenosis has been consistently recognized. The clinical use of CCTA in the context of surgical revascularization is indubitable, whereas its role in addressing coronary artery stent patency requires further technical refinement. Ongoing research points toward the comprehensive assessment of CAD, including integrative morphologic and functional evaluation of the myocardium and coronary vessels. Most recent reports emphasize the prognostic value and cost-effectiveness of CCTA. Hence, CCTA may emerge as one of the most important clinical tools in the assessment of CAD, but further research is warranted.
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