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KCE Reports 82 Multislice CT in Coronary Heart Disease 37
Figure 3: Clinical path of patients studied in trials and those deemed
appropriate for MSCT by current guidelines
Shaded area: patients studied in clinical trials so far. Dark grey area: patients in whom MSCT is
CHEST PAIN ANGINA
ATYPICAL CHEST PAIN
NEGATIVE ECG STRESS TEST POSITIVE
INCONCLUSIVE
NEGATIVE MPS/DSE POSITIVE
INCONCLUSIVE
APPROPRIATE
CANDIDATE FOR MSCT ?
STANDARD CARE.
CCA if APPROPRIATE.
STANDARD CARE.
CCA if APPROPRIATE.
STANDARD CARE.
CCA if APPROPRIATE.
currently advocated in international guidelines. 108, 109 Bottom area: terra icognita. MPS: myocardial
perfusion scintigraphy. DSE: dobutamine stress echocardiogram. CCA: conventional (invasive)
coronary angiography.
The most decisive evidence for judging the effectiveness of MSCT should come from
randomised controlled trials. MSCT can affect patient outcome when the information
obtained from it is used to guide decisions to start, withhold, modify or stop
treatment. 113 Only patients in whom coronary imaging is deemed appropriate but the
likelihood for revascularisation is low, should be enrolled in such a trial. If the potential
need for revascularisation is high, invasive CCA is a more efficient first step because it
allows to proceed to the therapeutic intervention (PCI) within the same procedure.
Noninvasive imaging by MSCT can e.g. be envisaged for reassurance of a patient (or
his/her cardiologist) or for making an early decision for discharge of a patient admitted
with acute chest pain from the emergency department. Randomisation of such patients
in a trial can take place at different decision points in the clinical path (after stress
testing, MPS, or DSE) and against several alternative diagnostic options (MPS, DSE,
CCA, sequential biomarkers). The outcome of such a trial should not focus on the
correctness of the anatomical diagnosis but on endpoints that are relevant to patients,
such as symptom control, prevention of MI, and prolongation of survival. From a
societal perspective, long term downstream costs differences between different
pathways should be obtained.
Key point
• There is an urgent need for evidence on (1) the diagnostic
performance of MSCT in real world clinical practice, (2) its effect on
patient outcomes (QoL, prevention of infarction, prolongation of
life) and (3) its cost-effectiveness as compared to diagnostic
pathways in which MSCT is not embedded.