Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
Ann Intern Med. 2010 May 18;152(10):630-9. doi: 10.7326/0003-4819-152-10-201005180-00003.
Computed tomography coronary angiography (CTCA) has become a popular noninvasive test for diagnosing coronary artery disease.
To compare the accuracy and clinical utility of stress testing and CTCA for identifying patients who require invasive coronary angiography (ICA).
Observational study.
University medical center in Rotterdam, the Netherlands.
517 patients referred by their treating physicians for evaluation of chest symptoms by using stress testing or ICA.
Stress testing and CTCA in all patients.
Diagnostic accuracy of stress testing and CTCA compared with ICA; pretest probabilities of disease by Duke clinical score; and clinical utility of noninvasive testing, defined as a pretest or posttest probability that suggests how to proceed with testing (no further testing if < or =5%, proceed with ICA if between 5% and 90%, and refer directly for ICA if > or =90%).
Stress testing was not as accurate as CTCA; CTCA sensitivity approached 100%. In patients with a low (<20%) pretest probability of disease, negative stress test or CTCA results suggested no need for ICA. In patients with an intermediate (20% to 80%) pretest probability, a positive CTCA result suggested need to proceed with ICA (posttest probability, 93% [95% CI, 92% to 93%]) and a negative result suggested no need for further testing (posttest probability, 1% [CI, 1% to 1%]). Physicians could proceed directly with ICA in patients with a high (>80%) pretest probability (91% [CI, 90% to 92%]).
Referral and verification bias might have influenced findings. Stress testing provides functional information that may add value to that from anatomical (CTCA or ICA) imaging.
Computed tomography coronary angiography seems most valuable in patients with intermediate pretest probability of disease, because the test can distinguish which of these patients need invasive angiography. These findings need to be confirmed before CTCA can be routinely recommended for these patients.
计算机断层扫描冠状动脉造影（CTCA）已成为一种用于诊断冠状动脉疾病的常用非侵入性检查方法。
比较负荷试验和 CTCA 对识别需要进行有创冠状动脉造影（ICA）的患者的准确性和临床实用性。
观察性研究。
荷兰鹿特丹大学医学中心。
517 例由其治疗医生转诊进行负荷试验或 ICA 评估胸痛症状的患者。
所有患者均行负荷试验和 CTCA。
负荷试验和 CTCA 与 ICA 的诊断准确性；杜克临床评分的疾病先验概率；以及非侵入性检查的临床实用性，定义为一种先验或后验概率，提示如何进行检查（如果<或=5%，则无需进一步检查，如果在 5%至 90%之间，则进行 ICA，如果>或=90%，则直接进行 ICA）。
负荷试验不如 CTCA 准确；CTCA 敏感性接近 100%。在疾病先验概率较低（<20%）的患者中，阴性负荷试验或 CTCA 结果提示无需进行 ICA。在疾病先验概率为中等（20%至 80%）的患者中，阳性 CTCA 结果提示需要进行 ICA（后验概率，93%[95%置信区间，92%至 93%]），阴性结果提示无需进一步检查（后验概率，1%[置信区间，1%至 1%]）。对于先验概率较高（>80%）的患者，医生可以直接进行 ICA（后验概率，91%[95%置信区间，90%至 92%]）。
转诊和验证偏倚可能影响研究结果。负荷试验提供的功能信息可能增加解剖学（CTCA 或 ICA）成像的价值。
CTCA 似乎对疾病先验概率中等的患者最有价值，因为该检查可以区分这些患者中哪些需要进行有创性血管造影术。在 CTCA 可以常规推荐给这些患者之前，需要对这些发现进行确认。
