| Test | Indication | Population | Cost* |
|---|---|---|---|
| Coronary computed tomographic angiography | Evaluation of stable chest pain for coronary artery stenosis in patients without known heart disease | Intermediate-risk adults with suspected coronary artery disease | $360 |
*—Payment rate according to the Centers for Medicare and Medicaid Services clinical laboratory fee schedule (accessed July 12, 2024; zip code: 66211).16
Coronary computed tomographic angiography (CCTA) is a noninvasive radiology test used to evaluate for coronary artery stenosis by detecting high-risk atherosclerotic plaques and their volume and location.1 In 2021, the American College of Cardiology/American Heart Association Joint Committee recommended CCTA over invasive coronary angiography (ICA) or functional imaging for intermediate-risk patients with stable chest pain and no known coronary artery disease (CAD) to rule out coronary stenosis.2
Intermediate risk can be defined using different clinical decision pathways such as the HEART (history, electrocardiography, age, risk factors, and troponin) score for major cardiac events and the Thrombolysis in Myocardial Infarction score. The classification system groups CCTA findings from 0 to 5 based on the degree of coronary stenosis and location and recommends management options (Table 1).3
TABLE 1. CAD-RADS for Stable Chest Pain
| CAD-RADS category | Degree of coronary stenosis | Management options |
|---|---|---|
| 0 | 0% (none) | Offer reassurance |
| Consider nonatherosclerotic causes of chest pain | ||
| 1 | 1% to 24% (minimal) | Consider nonatherosclerotic causes of chest pain |
| Consider preventive therapy and risk-factor modification | ||
| 2 | 25% to 49% (mild) | Consider nonatherosclerotic causes of chest pain |
| Consider preventive therapy and risk-factor modification | ||
| 3 | 50% to 69% (moderate) | Consider further functional testing or hospital admission |
| Consider symptom-guided anti-ischemic and aggressive preventive pharmacotherapy, as well as risk-factor modifications | ||
| 4A | 70% to 99% (severe) in one or two vessels | Consider hospital admission with consideration for functional testing |
| Consider symptom-guided anti-ischemic and aggressive preventive pharmacotherapy, as well as risk-factor modifications | ||
| 4B | Left main artery > 50% or three-vessel obstructive disease > 70% | Consider hospital admission, with consideration for invasive coronary angiography with revascularization |
| Consider symptom-guided anti-ischemic and aggressive preventive pharmacotherapy, as well as risk-factor modifications | ||
| 5 | 100% (total occlusion) | Consider hospital admission with urgent invasive coronary angiography and revascularization if appropriate |
| Consider symptom-guided anti-ischemic and aggressive preventive pharmacotherapy, as well as risk-factor modifications | ||
| N | Nondiagnostic study | Recommend alternative diagnostic testing for coronary artery evaluation |
CAD-RADS = coronary artery disease reporting and data system.
Adapted with permission from Cury RC, Abbara S, Achenbach S, et al. CAD-RADSTM coronary artery disease - reporting and data system. J Cardiovasc Comput Tomogr. 2016;10(4):272.
ACCURACY
A study comparing CCTA with ICA as the reference standard in intermediate- to high-risk patients (n = 64 patients; 827 segments) showed that CCTA had a diagnostic accuracy of 96% for detecting 50% or greater luminal stenosis (sensitivity = 87%; specificity = 97%; positive likelihood ratio = 29; negative likelihood ratio = 0.13). In segments with 70% or greater luminal stenosis, diagnostic accuracy was 99% (sensitivity = 96%; specificity = 99%; positive likelihood ratio = 96; negative likelihood ratio = 0.04). For coronary artery segments analyzed in this study, 1% were considered uninterpretable because of motion artifacts, extensive calcifications, small vessel diameter, or blooming artifact from a stent.4
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