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Coronary CT angiography didn't impact risk of death or cardiac hospitalization for patients with suspected coronary artery disease (CAD) but did lead to more CAD diagnoses and interventions than did functional stress testing, a meta-analysis affirmed.

were 1.0% for coronary CT angiography and 1.1% for stress testing (RR 0.93, 95% CI 0.71-1.21), with similarity between strategies in the randomized trials analyzed whether patients had acute or stable chest pain.

Incidence of cardiac hospitalization was identical between groups (2.7% for both, RR 0.98, 95% CI 0.79-1.21), Andrew Foy, MD, of Penn State College of Medicine in Hershey, and colleagues reported online in JAMA Internal Medicine.

Coronary CT angiography was associated with reduced incidence of myocardial infarction (0.7% versus 1.1%, RR 0.71, 95% CI 0.53-0.96), but this association held only for stable chest pain (not acute cases). Importantly, excluding the SCOT-HEART trial (which assigned most patients in the CT angiography arm to functional stress testing) neutralized the statistically significant drop in MIs.

After CT angiography, those with stable or acute chest pain were more likely to undergo invasive coronary angiography (11.7% versus 9.1% for stress testing, RR 1.33, 95% CI 1.12-1.59) and revascularization (7.2% versus 4.5%, RR 1.86, 95% CI 1.43-2.43). A new diagnosis of CAD was also more common than with stress testing (18.3% versus 8.3%, RR 2.80, 95% CI 2.03-3.87).

Patients presenting with stable chest pain got started on aspirin or statin therapy more often after CT angiography.

"This analysis corroborates prior meta-analyses showing that coronary CT angiography compared with functional stress testing is associated with increased invasive coronary angiography and revascularization procedures," Foy's group said. "We hypothesize that at least some of these additional procedures are associated with the finding of incidental CAD that is not causing symptomatic ischemia and would not have been detected with functional stress testing alone."

In an , Todd Villines, MD, of Walter Reed National Military Medical Center in Bethesda, Md., and Leslee Shaw, PhD, of Emory University School of Medicine in Atlanta, suggested that the observed reduction in MI with CT angiography may have had to do with the greater uptake of preventative therapies in that cohort.

They also noted that in November 2016, the U.K.'s National Institute for Health and Care Excellence (NICE) updated its guidelines to recommend coronary CT angiography as the initial test for all patients with suspected CAD.

"The findings of the current study, in our opinion, support the approach by NICE and demonstrate that coronary CT angiography should be more broadly available to patients without known CAD who present with acute or stable chest pain," Villines and Shaw wrote.

"Strategies to improve the specificity of coronary CT angiography, such as selective ischemia-testing, may serve to further reduce the number of patients referred to invasive coronary angiography following coronary CT angiography to only those most likely to benefit from revascularization."

The meta-analysis by Foy and colleagues included 13 randomized trials with CT angiography (n=10,315) and stress testing arms (n=9,777). Participants (mean age 58 years, 49.0% women) were followed for 18 months on average.

Having no access to no patient-level data, the authors were unable to adjust for differences between groups. Additionally, they commented that most trials they included differed by CT angiography strategy, and different modes of stress testing existed across studies as well.