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This editorial refers to ‘Diagnosing coronary artery disease after a positive coronary computed tomography angiography: the Dan-NICAD open label, parallel, head to head, randomized controlled diagnostic accuracy trial of cardiovascular magnetic resonance and myocardial perfusion scintigraphy’, by L. Nissen et al., pp. 369–377.

Coronary computed tomography angiography (CCTA) is increasingly used to examine patients with stable chest pain of recent onset and suspected coronary artery disease (CAD).1,2 In patients with low-to-intermediate pre-test probability of disease, it has high diagnostic accuracy for CAD when using invasive coronary angiography (ICA) as a reference standard.2,3 Sensitivity of CCTA is excellent, but specificity of CCTA is lower, which may lead to overestimation of the severity of CAD. In a recent meta-analysis assessing diagnostic performance of cardiac imaging methods to diagnose haemodynamically significant CAD defined as a significant pressure difference across stenosis during hyperaemia by invasive fractional flow reserve (FFR), sensitivity of CCTA was 90%, but specificity only 39%.4 Given the evidence that FFR guided revascularizations improve symptoms and event-free survival when compared with a coronary stenosis-guided strategy,2 strategies to improve the specificity of CCTA are warranted. Corresponding to the invasive approach, selective ischaemia-testing in patients with abnormal CCTA can be assumed to identify the patients most likely to benefit from revascularization.

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Editorial
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