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22 Multislice CT in Coronary Heart Disease KCE Reports 82 (appendix). i We decided not to repeat this search but instead to extend it by searching Medline (through PubMed) and EMBASE from Jan, 1, 2007 through March, 10, 2008 for trials and reviews on 64(or higher)-SCT in native coronary vessels (i.e. not in bypass grafts or coronary stents). SUMSearch (“multislice CT”) was also consulted. On April, 7, 2008 these searches were repeated. Diagnostic studies were considered eligible if they enrolled at least 30 patients with proven or suspected CAD, using 64-(or higher)SCT compared with CCA as the reference to identify significant stenosis and if they provided per-patient data on native coronary arteries. Significant coronary luminal stenosis was defined as >50% reduction in diameter of the vessel by quantitative CCA or visual estimation of CCA. Trials assessing patient outcomes based on MSCT results were also retrieved. It turned out that identification of those trials was not straightforward, presumably because of variable and less strict methodological nature of this kind of studies and their inferior indexation in major literature databases. This part of our literature search consequently is less stringent and connot be regarded as a formal systematic review. We could only identify one randomised controlled outcome trial. 67 Systematic reviews that reported a meta-analysis of the diagnostic accuracy of MSCT used within the defined scope of this report, were eligible. The following search string was used in PubMed: ("Tomography, X-Ray Computed"[Mesh] AND "Coronary Artery Disease"[Mesh]) AND (sensitiv*[Title/Abstract] OR sensitivity and specificity[MeSH Terms] OR diagnos*[Title/Abstract] OR diagnosis[MeSH:noexp] OR diagnostic *[MeSH:noexp] OR diagnosis,differential[MeSH:noexp] OR diagnosis[Subheading:noexp]) AND (("2007/01/01"[PDat]:"3000"[PDat]) AND (Humans[Mesh]) AND (English[lang])) From the resulting 170 hits, based on title and abstract, and after excluding articles that were included in Abdulla’s SR, 66 4 diagnostic studies, 68-71 1 outcome study, 72 and 2 SRs 39, 73 were selected. A second search string was tried within PubMed, more specifically addressing outcome studies, but no additional articles were identified by it: ("Tomography, X-ray Computed" [Mesh] AND "Coronary Artery Disease" [Mesh]) AND (incidence[MeSH:noexp] OR mortality[MeSH Terms] OR follow up studies[MeSH:noexp] OR prognos*[Text Word] OR predict*[Text Word] OR course*[Text Word]) AND (("2007/01/01"[PDat]:"3000"[PDat]) AND (Humans[Mesh]) AND (English[lang])) On April, 7, 2008 a third search was performed in PubMed, simply by using the unlimited entry “dual-source [ti]”. This resulted in 80 hits. Four were related to dualsource CT scanning of the coronary arteries and matched our eligibility criteria and were not detected by previous searches. Of these, three were originating from the same group of researches and were duplicates (with increasing numbers of included patients). 33, 74, 75 33, 76 This search eventually resulted in two additional diagnostic trials. In EMBASE, we used the following search string: 'multidetector computed tomography'/exp AND 'ischemic heart disease'/exp AND [english]/lim AND [humans]/lim AND [embase]/lim AND [2007-2008]/py This resulted in 202 hits. Based on title and abstract, and after excluding articles that were included in Abdulla’s SR, 66 or were identified by PubMed, three diagnostic studies, 40, 77, 78 two outcome studies, 79, 80 and one SR 81 were identified. Two additional articles were found via SUMSearch by using the entry “multislice CT”: one SR 82 and one single center trial. 83 Handsearching revealed one extra outcome study. 67 i http://www.cochrane.nl/index.html
KCE Reports 82 Multislice CT in Coronary Heart Disease 23 In conclusion, in addition to the trials selected by Abdulla, 66 we retrieved 10 additional primary diagnostic papers that were published in 2007 or 2008. Moreover, we selected 4 prognostic studies from 2 different research groups and 4 meta-analyses Table 5. Table 5: Number of trials identified via different search engines and number of trials qualified as eligible. N identified N eligible diagnostic outcome SR PubMed 250 2 1 2 EMBASE (excl PubMed) 202 3 2 1 SUMSearch + handsearching 104 1 1 1 TOTAL 10 4 4 The quality of systematic reviews was assessed using the Dutch Cochrane Centre checklist (http://www.cochrane.nl/index.html) (cf Figure 4 in the appendix to this report). The quality of primary diagnostic papers was assessed by means of the QUADAS tool as shown in Figure 5 and Table 18 in the appendix. 84 3.1.2 Data extraction Demographic, methodological (clinical context, exclusion criteria) and technical data, numbers of patients, use of beta-blocking agents, radiation exposure, numbers of true positives, false positives, true negatives and false negatives were extracted from each study. The results at a patient-level and the prevalence of disease (defined as at least one >50% coronary artery narrowing by CCA) were also extracted. Key points • This report predominantly focuses on the diagnostic performance of 64-SCT in CAD as studied in trials that were published in the year 2007 and the beginning of 2008. • Data are added to those from a systematic review on 64-SCT that searched literature until April 2007 and was published in December 2007. • We selected two relevant HTA reports, 4 systematic reviews and 10 primary diagnostic trials. 3.2 LITERATURE REVIEW 3.2.1 Health Technology Assessments 64-SCT devices were only released in the fall of 2004 and the Andalusian Agency’s report 61 published in February 2006 was the first in the series of HTA-reports that we retrieved that included at least one 64-SCT study. 85 Also the report from Harvard Pilgrim included only one primary trial that made use of 64-slice technology. 35 A rapid assessment was published by the National Horizon Scanning Unit of the Adelaide HTA 86 and incorporated two such studies. 87, 88 The most comprehensive HTA reports dealt with MSCT for screening in asymptomatic populations, which is beyond the scope of 41, 42 the current report. The Tec Blue Cross Blue Shield 63 report of August 2006 and the AHRQ 64 technology assessment released in October 2006, each included six 64-SCT trials. In October 2007, the California Technology Assessment Forum issued a report (which we did not consider a full HTA) that can be regarded as an update of the Tec BCBC report of August 2006 and to which it added one additional 64-SCT trial. 70
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