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Original article

Vol. 149 No. 0304 (2019)

Use of coronary computed tomography angiography in clinical practice – single centre experience in Switzerland in light of current recommendations based on pretest probability considerations

  • Evelyne Neurauter
  • Sebastian Leschka
  • Simon Wildermuth
  • Niklas F. Ehl
  • Lucas Joerg
  • Hans Rickli
  • Micha T. Maeder
Cite this as:
Swiss Med Wkly. 2019;149:w20010



Coronary computed tomography angiography (CCTA) is recommended as a first-line option for the exclusion of coronary artery disease in patients with low to intermediate (15–50%) pretest probability. We aimed to study the use of CCTA in clinical practice in a single centre in Switzerland in light of this recommendation.


In 523 consecutive patients (age 56 ± 13 years, 48% females) undergoing CCTA during a period of 2 years, the pretest probability of coronary artery disease was assessed using the revised Diamond-Forrester model (CAD consortium score). In patients who had invasive coronary angiography following CCTA, angiographic findings and the consequences regarding management are reported.


The majority of patients (n = 316; 60%) had a pretest probability <15%, 188/523 (36%) had a pretest probability between 15 and 50%, and 19/523 (4%) had a pretest probability >50%. The prevalences of coronary artery disease (≥50% lumen diameter reduction) by CCTA in patients with pretest probability <15%, 15–50%, and >50% were 25/316 (8%), 45/188 (24%) and 8/19 (42%), respectively. In 438/523 patients (84%), a CCTA scan showing no coronary artery disease represented the final diagnostic step. In patients undergoing invasive coronary angiography (n = 59, age 58 ± 9 years, 88% with coronary artery disease by CCTA), coronary artery disease was found in 47/59 (80%) patients and 36/59 (61%) patients underwent revascularisation. The prevalences of coronary artery disease by invasive coronary angiography in patients with pretest probability <15%, 15–50%, and >50% were 14/21 (67%), 28/32 (88%) and 5/6 (83%).


The present data suggest that the currently used pretest probability model is still imperfect and that guideline recommendations regarding pretest probability use for the selection of CCTA candidates are not followed completely. Still, in more than 80% of patients coronary artery disease could be excluded by CCTA, while CCTA also detected a significant number of patients with coronary artery disease in the low pretest probability population. Thus, the data suggest a very judicious use of CCTA as a gatekeeper for invasive coronary angiography in current practice.


  1. Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, et al.; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation. 2018;137(12):e67–492. [doi:.].
  2. Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949–3003. [doi:.].
  3. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979;300(24):1350–8. [doi:.].
  4. Genders TS, Steyerberg EW, Alkadhi H, Leschka S, Desbiolles L, Nieman K, et al. CAD Consortium. A clinical prediction rule for the diagnosis of coronary artery disease: validation, updating, and extension. Eur Heart J. 2011;32(11):1316–30. [doi:.].
  5. Mordi IR, Badar AA, Irving RJ, Weir-McCall JR, Houston JG, Lang CC. Efficacy of noninvasive cardiac imaging tests in diagnosis and management of stable coronary artery disease. Vasc Health Risk Manag. 2017;13:427–37. [doi:.].
  6. Dweck MR, Williams MC, Moss AJ, Newby DE, Fayad ZA. Computed Tomography and Cardiac Magnetic Resonance in Ischemic Heart Disease. J Am Coll Cardiol. 2016;68(20):2201–16. [doi:.].
  7. Salavati A, Radmanesh F, Heidari K, Dwamena BA, Kelly AM, Cronin P. Dual-source computed tomography angiography for diagnosis and assessment of coronary artery disease: systematic review and meta-analysis. J Cardiovasc Comput Tomogr. 2012;6(2):78–90. [doi:.].
  8. Bittencourt MS, Hulten E, Polonsky TS, Hoffman U, Nasir K, Abbara S, et al. European Society of Cardiology-Recommended Coronary Artery Disease Consortium Pretest Probability Scores More Accurately Predict Obstructive Coronary Disease and Cardiovascular Events Than the Diamond and Forrester Score: The Partners Registry. Circulation. 2016;134(3):201–11. [doi:.].
  9. Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M, Jr, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol. 1990;15(4):827–32. [doi:.].
  10. Pryor DB, Harrell FE, Jr, Lee KL, Califf RM, Rosati RA. Estimating the likelihood of significant coronary artery disease. Am J Med. 1983;75(5):771–80. [doi:.].
  11. Wasfy MM, Brady TJ, Abbara S, Nasir K, Ghoshhajra BB, Truong QA, et al. Comparison of the Diamond-Forrester method and Duke Clinical Score to predict obstructive coronary artery disease by computed tomographic angiography. Am J Cardiol. 2012;109(7):998–1004. [doi:.].
  12. Kumamaru KK, Arai T, Morita H, Sekine T, Takamura K, Takase S, et al. Overestimation of pretest probability of coronary artery disease by Duke clinical score in patients undergoing coronary CT angiography in a Japanese population. J Cardiovasc Comput Tomogr. 2014;8(3):198–204. [doi:.].
  13. Nielsen LH, Bøtker HE, Sørensen HT, Schmidt M, Pedersen L, Sand NP, et al. Prognostic assessment of stable coronary artery disease as determined by coronary computed tomography angiography: a Danish multicentre cohort study. Eur Heart J. 2017;38(6):413–21.
  14. Min JK, Dunning A, Lin FY, Achenbach S, Al-Mallah M, Budoff MJ, et al. CONFIRM Investigators. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol. 2011;58(8):849–60. [doi:.].
  15. Pontone G, Andreini D, Bartorelli AL, Bertella E, Cortinovis S, Mushtaq S, et al. A long-term prognostic value of CT angiography and exercise ECG in patients with suspected CAD. JACC Cardiovasc Imaging. 2013;6(6):641–50. [doi:.].
  16. Van Mieghem CAG. CT as gatekeeper of invasive coronary angiography in patients with suspected CAD. Cardiovasc Diagn Ther. 2017;7(2):189–95. [doi:.].
  17. Mark DB, Shaw L, Harrell FE, Jr, Hlatky MA, Lee KL, Bengtson JR, et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med. 1991;325(12):849–53. [doi:.].
  19. Patel MR, Peterson ED, Dai D, Brennan JM, Redberg RF, Anderson HV, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med. 2010;362(10):886–95. [doi:.].
  20. Stocker TJ, Deseive S, Leipsic J, Hadamitzky M, Chen MY, Rubinshtein R, et al. PROTECTION VI investigators. Reduction in radiation exposure in cardiovascular computed tomography imaging: results from the PROspective multicenter registry on radiaTion dose Estimates of cardiac CT angIOgraphy iN daily practice in 2017 (PROTECTION VI). Eur Heart J. 2018;39(41):3715–23. [doi:.].

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