Coronary CT angiography alone versus with CT perfusion: a systematic review and meta-analysis assessing approaches for chest pain.

Objectives: To evaluate the prognostic value of stress Computed Tomography Perfusion (CTP) in patients with suspected or known coronary artery disease.

Materials And Methods: All studies evaluating patients with chest pain with CTP plus coronary computed tomography angiography (CCTA) alone or versus CCTA were included. The primary analysis included studies comparing CCTA plus CTP vs CCTA alone, while in the secondary analysis we analyzed the incidence of each outcome across all seven studies, two- and single-arm.

Results: Seven double- and single-arm studies were included (two randomized controlled trials and five observational ones) with 3587 patients (2101 evaluated with CTP plus CCTA and 1486 with CCTA alone).In the primary analysis including 4 studies, after a median follow-up of 17 months, the rates of MACEs (OR 1.19, 95% CI 0.91-1.57, p = 0.21) and all-cause death (OR 0.41, 0.11-1.47, p = 0.17) were similar. Patients managed according to CCTA alone had higher rates of total ICA (OR 2.42, 1.99-2.94, p < 0.00001) and ICA without subsequent revascularization (OR 2.85, 1.23-6.61, p = 0.01). Conversely, the rate of ICA with subsequent revascularization was higher in patients who underwent CCTA plus CTP (OR 0.39, 0.22-0.69, p = 0.001). There were no significant differences in terms of recurrent MI (OR 0.94, 0.15-5.83, p = 0.95) and unplanned revascularization (OR 0.69, 0.19-2.51, p = 0.57, all CI 95%) between the two approaches. These results were confirmed in the secondary analysis.

Conclusion: A coronary imaging approach based on perfusion evaluation in addition to anatomic assessment was comparable to CCTA alone in terms of MACE, myocardial infarctions and unplanned revascularizations up to 2 years. Patients evaluated with CTP less frequently underwent ICA, which did, however, result in a higher rate of stent implantation.

Key Points: Question Does the addition of stress Computed Tomography Perfusion (CTP) to coronary computed tomography angiography (CCTA) improve the diagnostic and prognostic evaluation of patients with chest pain compared to CCTA alone? Findings Stress CTP combined with CCTA reduces unnecessary invasive coronary angiography and increases revascularization rates without significantly impacting MACE, myocardial infarction, or unplanned revascularization. Clinical relevance Incorporating stress CTP into CCTA optimizes care by reducing unnecessary invasive procedures and improving tailored treatment strategies for patients with stable and unstable chest pain.