Coronary computed tomography angiography in patients with chronic chest pain: Systematic review of evidence base and cost-effectiveness

The diagnostic evaluation of patients without known coronary artery disease presenting with chronic stable chest pain or angina equivalent is complex. Imaging often plays a role in diagnosis and risk stratification, and a variety of techniques are available, each with inherent and situation-specific advantages and disadvantages. Coronary computed tomography angiography (CTA) has been proposed as a fast, noninvasive, reliable test to rule out disease in this population, with potential improvements in costs and outcomes compared with alternative strategies. The relatively rapid rise in coronary CTA utilization, however, has led to strong calls from clinicians and health care policy organizations alike to provide high-level evidence supporting its use. The present article provides a review of the available evidence. Alternative diagnostic strategies and currently accepted indications for coronary CTA are discussed, followed by evaluation of the evidence on diagnostic accuracy, prognostic value, effect on outcomes and health care utilization, and safety. We end with a brief outlook on future developments.