Coronary Computed Tomography Angiography (CCTA) vs Functional Imaging in the Evaluation of Stable Ischemic Heart Disease

Management of patients with stable ischemic heart disease remains challenging, in part due to the inability of non-invasive testing to accurately identify those who may benefit from coronary revascularization. For decades, use of functional testing, such as nuclear perfusion imaging, stress echocardiography, and exercise electrocardiography, has remained a pivotal component of algorithms designed to evaluate anginal pain. Over the past several years, however, a growing body of evidence has developed to support anatomical imaging, with special attention given to coronary computed tomography angiography (CCTA) as the more diagnostically and prognostically accurate non-invasive testing modality. The results of several large randomized controlled trials, as well as their subsequent post hoc analyses, have led to the escalation of CCTA as the first-line test in international guidelines for the evaluation of stable chest pain in patients with low-to-intermediate risk of coronary artery disease. Moreover, recognition of CCTA and its role in improving patient outcomes has driven key change in healthcare policy coverage, leading to streamlined reimbursement and the elimination of prior authorization when utilized in the appropriate setting. Given the rapidly accumulating supportive evidence, the next iteration of the American College of Cardiology/American Heart Association guidelines for stable ischemic heart disease should position CCTA as the first-line test in qualifying patients. Here, we review current literature evaluating anatomical and functional imaging, and formulate a discussion on clinical implementation, limitations of currently available data, and direction for CCTA-based future research.