Assessing suspected angina: requiem for coronary computed tomography angiography or exercise electrocardiogram?

Abstract

Assessment of symptoms in patients with suspected stable angina pectoris forms an important part of the daily clinical activity of most cardiologists. In the presence of very typical symptoms, history taking by an experienced cardiologist may be sufficient to make the diagnosis of stable angina pectoris; however, many patients present with atypical symptoms. Here, testing is necessary to confirm the diagnosis of angina pectoris, to exclude alternative diagnoses and most importantly to risk stratify patients. During the last decades, the arsenal of diagnostic methods to examine patients with suspected stable angina has expanded enormously. Today, we are able to visualize non-invasively the coronary arteries, and different imaging methods are available for assessing the presence, extent, and severity of myocardial ischaemia. The increasing constraints on healthcare expenditures in the ageing populations in Europe may stimulate healthcare providers to look for the most cost-effective approach in the diagnosis and treatment of ischaemic heart diseases. In the future, cardiologists may become more accountable for prescribing the use of different diagnostic methods, or worse, healthcare providers may introduce managed care schemes that allow only predefined diagnostic algorithms. Healthcare providers in Europe advised by clinical healthcare excellence centres are already considering changing the reimbursement of some diagnostic techniques in cardiology in order to stimulate the practice of more cost-effective methods in the diagnosis of stable coronary artery disease (CAD). Recently, the results of two major clinical trials have been published that compared anatomic imaging by coronary computed tomography angiography (CCTA) with functional imaging by various methods1 and with standard care2 in the diagnosis of patients with suspected stable CAD. The imminent changes in healthcare reimbursement of diagnostic techniques …