Diagnostic performance of non-invasive imaging for stable coronary artery disease: A meta-analysis

Background: To determine diagnostic performance of non-invasive tests using invasive fractional flow reserve (FFR) as reference standard for coronary artery disease (CAD). Methods: Medline, Embase, and citations of articles, guidelines, and reviews for studies were used to compare non-invasive tests with invasive FFR for suspected CAD published through March 2017. Results: Seventy-seven studies met inclusion criteria. The diagnostic test with the highest sensitivity to detect a functionally significant coronary lesion was coronary computed tomography (CT) angiography [88%(85%–90%)], followed by FFR derived from coronary CT angiography (FFR_CT) [85%(81%–88%)], positron emission tomography (PET) [85%(82%–88%)], stress cardiac magnetic resonance (stress CMR) [81%(79%–84%)], stress myocardial CT perfusion combined with coronary CT angiography [79%(74%–83%)], stress myocardial CT perfusion [77%(73%–80%)], stress echocardiography (Echo) [72%(64%–78%)] and stress single-photon emission computed tomography (SPECT) [64%(60%–68%)]. Specificity to rule out CAD was highest for stress myocardial CT perfusion added to coronary CT angiography [91%(88%–93%)], stress CMR [91%(90%–93%)], and PET [87%(86%–89%)]. Conclusion: A negative coronary CT angiography has a higher test performance than other index tests to exclude clinically-important CAD. A positive stress myocardial CT perfusion added to coronary CT angiography, stress cardiac MR, and PET have a higher test performance to identify patients requiring invasive coronary artery evaluation.