Use Of Coronary Computed Tomography Angiography Research Articles

Abstract 14133: Use of Computed Tomography Coronary Angiography in Pre-Operative Risk Assessment in Non-Cardiac Surgeries

Introduction: Computed Tomography Coronary Angiography (CTCA) has emerged as a promising tool for detecting and evaluating coronary artery diseases (CAD). However, the role of CTCA for risk assessment tool for patients undergoing noncardiac surgeries is unknown. Methods: We searched databases like PubMed and Google Scholar to compile the literature including reviews, meta-analyses, scientific articles, and guidelines, describing the use of CTCA in the diagnosis and evaluation of cardiac risk assessment in noncardiac surgeries. Results: Based on our literature review we found that CTCA is a promising adjunctive tool for preoperative assessment in noncardiac surgeries to evaluate cardiac risk with high sensitivity and negative predictive value. VISION-CTA sub study showed that CTCA combined with Myocardial Perfusion Imaging (MPI) predicts major adverse cardiac events within 30 days of surgery with higher accuracy than either test alone. McCarthy KJ et al found an increase in the proportion of CTCAs performed from before 2018, 2018 to post 2018, (3%, 6.3%, and 26.3% respectively; p <0.001) and obstructive CAD diagnosis using CTCA (0%, 30%, and 51.4% respectively; p = 0.04). Hence supporting a shift to non-invasive CTCA for pre-operative assessment of liver transplant candidates. According to Ahn J et al, CTCA shows 100% sensitivity and 99.3% negative predictive value in predicting major adverse cardiac events and can be used to stratify intermediate risk noncardiac surgery patients. Conclusions: CTCA is a valuable risk assessment tool in patients undergoing noncardiac surgery because of its high sensitivity and negative predictive value. There is a need for further research and guidelines for using CTCA as a risk assessment tool in noncardiac surgeries.

Contemporary Chest Pain Evaluation: TheAustralian Case for Cardiac CT.

Computed tomography coronary angiography (CTCA) is a non-invasive diagnostic modality that provides a comprehensive anatomical assessment of the coronary arteries and coronary atherosclerosis, including plaque burden, composition and morphology. The past decade has witnessed an increase in the role of CTCA for evaluating patients with both stable and acute chest pain, and recent international guidelines have provided increasing support for a first line CTCA diagnostic strategy in select patients. CTCA offers some advantages over current functional tests in the detection of obstructive and non-obstructive coronary artery disease, as well as for ruling out obstructive coronary artery disease. Recent randomised trials have also shown that CTCA improves prognostication and guides the use of guideline-directed preventive therapies, leading to improved clinical outcomes. CTCA technology advances such as fractional flow reserve, plaque quantification and perivascular fat inflammation potentially allows for more personalised risk assessment and targeted therapies. Further studies evaluating demand, supply, and cost-effectiveness of CTCA for evaluating chest pain are required in Australia. This discussion paper revisits the evidence supporting the use of CTCA, provides an overview of its implications and limitations, and considers its potential role for chest pain evaluation pathways in Australia.

Cost-effectiveness of rapid assessment of potential ischaemic heart disease with CT coronary angiography

ObjectivesTo estimate the cost-effectiveness of early CT coronary angiography (CTCA) for intermediate risk patients with suspected acute coronary syndrome (ACS), compared with standard careMethodsWe performed within-trial economic analysis using data...

Diagnostic performance of coronary CTA and CT-FFR for the detection of coronary artery disease in routine TAVI work-up

Abstract Objectives To assess the diagnostic performance of CT-FFR for the diagnosis of CAD in the work-up for TAVI. Background Work-up for transcatheter aortic valve implantation (TAVI) currently utilizes computed tomography (CT) to evaluate annulus diameter and peripheral vascular access, plus invasive coronary angiography (ICA) to assess significant coronary artery disease (CAD). ICA might partially be redundant with the use of Coronary CT Angiography (CCTA). Prior studies found improvement of the diagnostic accuracy of CCTA by use of CT derived fractional flow reserve (CT-FFR). Methods Consecutive patients with severe symptomatic aortic valve stenosis who underwent TAVI work-up between 2015–2019 were included in this cross-sectional study. All patients underwent CCTA and ICA within 3 months and diagnostic performance of both CCTA and CT-FFR were assessed using ICA as reference. Results Seventy-six of the 338 patients included in the analysis had ≥1 significant coronary stenosis at ICA. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy per-patient were 76.9%, 64.5%, 34.0%, 92.1% and 66.9% for CCTA and 84.6%, 88.3%, 63.2%, 96.0% and 87.6% for CT-FFR. The area under the receiver-operating characteristic-curve significantly differ between CCTA and CT-FFR (0.84 versus 0.90 p=0.02). A CT-FFR guided approach could avoid ICA in 57.1% versus 43.6% using CCTA. Conclusions CT-FFR significantly improves the diagnostic accuracy of CCTA without additional testing and increases the proportion of patients in whom ICA could have been safely avoided It has the potential to be integrated in the current clinical work-up for TAVI for diagnosing stable CAD requiring treatment. Funding Acknowledgement Type of funding sources: None.

Use of Coronary CT Angiography as a Screening Tool for Coronary Artery Disease in Asymptomatic Healthy Individuals or Patients

심장 돌연사 환자들은 종종 흉통 또는 운동성 호흡곤란 등의 전조증상이 나타나지 않기 때문에 잠재적인 무증상 관상동맥 질환을 조기에 발견하는 것이 매우 중요하다. 관상동맥 전산화단층촬영 혈관조영술은 방사선 노출로 인한 위험성 때문에 무증상 환자에서 스크리닝 검사로 정당화되지 못했었지만 최근에 전산화단층촬영 기술의 비약적인 발전으로 방사선량을 1 mSv 미만으로 최소화함으로써 무증상 환자의 관상동맥 질환 선별 검사의 유용성에 대한 많은 연구가 진행되어 왔다. 그러나, 여전히 무증상 정상인 또는 환자의 관상동맥 질환 선별 검사에 대한 관상동맥 전산화단층촬영 혈관조영술의 유용성에 대해서는 다양한 의견들이 있다. 이 종설에서는 무증상 정상인 또는 환자들에게 관상동맥 질환 선별 검사로 관상동맥 칼슘 점수와 관상동맥 전산화단층촬영 혈관조영술 유용성에 대해서 다양한 문헌고찰을 통해서 알아보았다. 관상동맥 전산화단층촬영 혈관조영술상 무증상 정상인의 2.6%에서 70% 이상의 유의한 관상동맥 협착이 발견되었고, 선별 목적의 관상동맥 전산화단층촬영 혈관조영술이 무증상 건강한 사람의 미래의 심혈관 질환 발생을 예측할 수 있다. 그러나 현재 미국국립보건원에서 진행하고 있는 SCOT-HEART 2 연구가 끝나면 관상동맥 전산화단층촬영 혈관조영술이 무증상 성인의 심혈관 예방에 선별 검사로 적절한지 결정을 내릴 수 있을 것으로 생각된다.

Cardiac Care of Non-COVID-19 Patients During the SARS-CoV-2 Pandemic: The Pivotal Role of CCTA.

Aim: The aim of this study is to evaluate the potential use of coronary CT angiography (CCTA) as the sole available non-invasive diagnostic technique for suspected coronary artery disease (CAD) during the coronavirus disease 2019 (COVID-19) pandemic causing limited access to the hospital facilities.Methods and Results: A consecutive cohort of patients with suspected stable CAD and clinical indication to non-invasive test was enrolled in a hub hospital in Milan, Italy, from March 9 to April 30, 2020. Outcome measures were obtained as follows: cardiac death, ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina. All the changes in medical therapy following the result of CCTA were annotated. A total of 58 patients with a mean age of 64 ± 11 years (36 men and 22 women) were enrolled. CCTA showed no CAD in 14 patients (24.1%), non-obstructive CAD in 30 (51.7%) patients, and obstructive CAD in 14 (24.1%) patients. Invasive coronary angiography (ICA) was considered deferrable in 48 (82.8%) patients. No clinical events were recorded after a mean follow-up of 376.4 ± 32.1 days. Changes in the medical therapy were significantly more prevalent in patients with vs. those without CAD at CCTA.Conclusion: The results of the study confirm the capability of CCTA to safely defer ICA in the majority of symptomatic patients and to correctly identify those with critical coronary stenoses necessitating coronary revascularization. This characteristic could be really helpful especially when the hospital resources are limited

Use of Coronary CT Angiography to Predict Obstructive Lesions in Patients with Chest Pain without Enzyme and ST-Segment Elevation.

It is challenging to rule out acute coronary syndrome among chest pain patients without both ST-segment elevation in electrocardiography and troponin elevation at emergency departments (ED). The purpose of this study was to develop a prediction model for rapidly determining the occurrence of significant stenosis in coronary computed tomography angiography (CCTA). Retrospective observational cohort study was conducted with 904 patients who had presented with chest pain without troponin elevation and ST-segment changes and underwent CCTA between January 2017 and December 2018. The primary endpoint was the presence of significant stenosis on CCTA, defined as narrowing above 70% diameter. The logistic regression model was used for development a new predictive model. One hundred and thirty-four patients (14.8%) were shown severe stenosis. The independent associated factors for significant stenosis were age ≥65 years, male, diabetes, history of acute coronary syndrome, and typical chest pain. Based these results, we developed a new prediction model. The area under the curve was 0.782 (95% confidence interval 0.742–0.822). Moreover, score of ≥5 was chosen as cut-off values with 86.6% sensitivity and 56.4% specificity. In conclusion, among chest pain patients without ST changes and troponin elevation, the new score will be helpful to identify potential candidate for CCTA such as patients with significant stenosis.

Spontaneous Coronary Artery Dissection: An Underdiagnosed Clinical Entity-A Primer for Cardiac Imagers.

Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of myocardial infarction in young and middle-aged women that has gained increasing awareness in recent years. Its diagnosis presents a challenge. Invasive coronary angiography is the primary imaging modality for diagnosing SCAD; however, it carries risk in these patients, who have an increased predisposition to complications. Advances in CT technology enable robust noninvasive evaluation of the coronary arteries at low radiation doses and have been increasingly utilized for the diagnosis or resolution of SCAD, in hemodynamically stable patients or when diagnosis of SCAD is uncertain at invasive angiography, particularly in proximal vessels. However, criteria for the diagnosis of SCAD with use of coronary CT angiography (CCTA) have not been currently established, and sensitivity and specificity for diagnosis have not yet been defined. The appearance of SCAD at CCTA can be subtle and can be missed, especially in distal small-caliber coronary arteries; hence utilization of other noninvasive imaging multimodalities may help solve this diagnostic challenge. Accurate and prompt diagnosis is vital, as management of SCAD differs significantly from that of traditional atherosclerotic acute coronary syndromes, with conservative management preferred for the majority of SCAD patients, and invasive treatment reserved for those with ongoing or recurrent ischemia, heart failure, or hemodynamic compromise. The goal of this review is twofold: (a) to discuss the potential role of CCTA in the diagnosis of SCAD, and (b) to discuss the role of multimodality imaging that may improve diagnostic yield, guide management, and enable subsequent surveillance. An invited commentary by Ordovas is available online. Online supplemental material is available for this article. ©RSNA, 2021.

Implementation of CT Coronary Angiography as an Alternative to Invasive Coronary Angiography in the Diagnostic Work-Up of Non-Coronary Cardiac Surgery, Cardiomyopathy, Heart Failure and Ventricular Arrhythmias.

To assess the need for additional invasive coronary angiography (CAG) after initial computed tomography coronary angiography (CTCA) in patients awaiting non-coronary cardiac surgery and in patients with cardiomyopathy, heart failure or ventricular arrhythmias, and to determine differences between patients that were referred to initial CTCA or direct CAG, consecutive patients were included between August 2017 and January 2020 and categorized as those referred to initial CTCA (conform protocol), and to direct CAG (non-conform protocol). Out of a total of 415 patients, 78.8% (327 patients, mean age: 57.9 years, 67.3% male) were referred to initial CTCA, of whom 260 patients (79.5%) had no obstructive lesions (<50% DS). A total of 55 patients (16.8%) underwent additional CAG after initial CTCA, which showed coronary lesions of >50% DS in 21 patients (6.3% of 327). Eighty-eight patients (mean age: 66.0 years, 59.1% male) were directly referred to CAG (non-conform protocol). These patients were older and had more cardiovascular risk factors compared to patients that underwent initial CTCA (conform protocol), and coronary lesions of >50% DS were detected in 16 patients (17.2%). Revascularization procedures were infrequently performed in both groups: initial CTCA (3.0%), direct CAG (3.4%). The use of CTCA as a gatekeeper CAG in the diagnostic work-up of non-coronary cardiac surgery, cardiomyopathy, heart failure and ventricular arrhythmias is feasible, and only 17% of these patients required additional CAG after initial CTCA. Therefore, CTCA should be considered as the initial imaging modality to rule out CAD in these patients.

Use of CTFFR and CTCA to Diagnose and Triage Patients of INOCA: A Retrospective Study

Objectives: INOCA (Ischemia in non- obstructive coronary arteries) has been recognized as a global health problem and poses a diagnostic challenge to establish the diagnosis which involves first ruling out obstructive coronary artery disease by the use of CT coronary angiography (CTCA) or an invasive angiogram. Second step involves the use of intracoronary pressure and Doppler monitoring which is not only costly, time consuming and lacks easy availability. CTFFR has emerged as frontline tool in the non invasive evaluation of patients with stable chest pain. This retrospective study was designed to evaluate the spectrum of findings of ischemia on CTCA and CT FFR in patients with stable chest pain to determine if this protocol can be used to identify patients with INOCA before they are subjected to invasive protocol. Methods: This was a retrospective study of 500 consecutive patients of stable chest pain with more than >1mm ST depression on resting EKG and or positive stress test who underwent CTCA along with CTFFR evaluation using a prescribed CT angiographic protocol. Post processing was done to reconstruct multiplanar angiographic views followed by CT FFR evaluation. All patients with no obstruction or stenosis less than 50% and with CT FFR of <0.80 were labeled as having INOCA. Subcategorisation of all INOCA patients was done based on Vessel tapering index (VTI), Plaque volume Index (PVI) into four subtypes- TypeI (vasospastic), Type II (site specific atherosclerotic), Type III (distal macrovascular dysfunction- DMD), Type IV (mixed). Results: Study showed 122 (34%) patients of stable chest pain had INOCA. Types I, III formed the largest group of patients 38% and 31% followed by the other two subtypes and showed significant differences in the VTI and PVI along with reduced FFR of <.80 in all these patients. Conclusion: Use of CTCA and CTFFR can be used as a first line tool to not only rule out obstructive coronary disease with ischemia but also to non invasively detect INOCA in patients with stable chest pain before subjecting these patients for further invasive protocols and can influence accurate management of such patients.

The Use of CT Coronary Angiography and CT Fractional Flow Reserve in the Investigation of Patients With Suspected Coronary Artery Disease.

ObjectiveTo assess the diagnostic performance of CT fractional flow reserve (CT-FFR) and to assess whether its use in addition to CT coronary angiography (CTCA) changed the investigation and management of patients with suspected coronary artery disease (CAD).MethodA retrospective case note review was carried out for 200 consecutive patients at Russells Hall Hospital, Dudley, United Kingdom, who had CTCA sent for Heartflow CT-FFR analysis (HeartFlow, Redwood City, CA) between January 2018 and December 2019.ResultsPatients with CT-FFR > 0.8 were significantly less likely to require further investigation with coronary angiography (p: < 0.00001) than those with CT-FFR < 0.8. The use of CT-FFR significantly reduced need for further functional imaging (6% vs 26%) (p: 0.00012). A total of 15 patients in this study had both a CT-FFR and an invasive FFR measured, with seven (46.66%) of the CT-FFRs correlating with the invasive FFR. Approximately 54% of patients who had a CT-FFR < 0.8 were found to have an invasive FFR of >0.8.Of the 56 patients who underwent coronary angiography, the CT Coronary Artery Disease-Reporting and Data System (CAD-RADS) and angiography CAD-RADS were the same in 66% of the cases with 82% of CT CAD-RADS results being within ±1 of the angiography CAD-RADS.ConclusionThe use of CT-FFR alongside CTCA led to a significant reduction in need for coronary angiography and functional testing. Further studies are required to look at the diagnostic accuracy of CT-FFR in direct comparison with invasive FFR.

The ISCHEMIA Trial: Implication for Cardiac Imaging in 2020 and Beyond.

Establishing a diagnosis of coronary artery disease (CAD) is more difficult than it would seem. Diagnosis of CAD can be approached in two ways: detection of ischemia (often with stress myocardial perfusion at SPECT, PET, and cardiac MRI) and visualization of the coronary artery anatomy to demonstrate stenosis (noninvasively with cardiac CT). In addition to providing further supportive evidence for the use of coronary CT angiography as the first-line test for the evaluation of CAD, the ISCHEMIA trial also resulted in some interesting findings with regard to imaging; these findings resulted in the open-ended question of "What does this mean for imagers?" © RSNA, 2020.

CORONARY CTA AND CT-DERIVED FRACTIONAL FLOW RESERVE: GATEKEEPERS TO INVASIVE ANGIOGRAPHY IN PATIENTS WITH HIGH PRE-TEST PROBABILITY OF CORONARY ARTERY DISEASE

Recently, some Radiology Benefit Managers have adopted the use of coronary CT angiography (CTA) and CT-derived fractional flow reserve (FFRCT) to determine appropriate referral for invasive coronary angiography (ICA). This study examined this approach in patients with high pre-test probability (PTP

Cardiac Chest Pain Evaluation In Patients With Diabetes And An Intermediate Probability Of Cad (Coronary Artery Disease)

Background and Aims: The 2016 update to NICE guideline for the investigation of new onset stable chest pain recommends use of CT coronary angiography (CTCA) as first line investigation in intermediate risk patients.

Serial Coronary Plaque Assessment Using Computed Tomography Coronary Angiography

Serial Coronary Plaque Assessment Using Computed Tomography Coronary Angiography

Practice Standards Developed and Quality Improvement for Use of Coronary CT Angiography in Taiwan

Practice Standards Developed and Quality Improvement for Use of Coronary CT Angiography in Taiwan

A Rare Case of Single Right Coronary Artery with Absent Left Main Coronary Artery

A 54-year-old woman presented with abdominal pain and diarrhoea, and had new T-wave inversion on electrocardiogram in leads V2–V6. Past history included recurrent deep vein thrombosis/pulmonary embolism and a recent subtotal colectomy for ulcerative colitis. The patient denied chest pain and serial troponin I measurements were normal (<0.040 μg/L). Postoperative ileus was the likely cause of abdominal pain. Echocardiography revealed impaired left ventricular (LV) systolic function (LV ejection fraction 35–40%). Coronary angiography was performed and the left main coronary artery (LMCA) could not be located despite cuspal injections, ascending aortogram, and left ventriculogram. A dominant right coronary artery (RCA) was visualised, which passed around the left ventricular apex to the area normally supplied by the obtuse marginal, diagonal, and distal left anterior descending arteries. Computed tomography coronary angiography (CTCA) revealed a superdominant RCA supplying the LV apex and lateral wall with no LMCA coming off the left coronary cusp. The left circumflex was small and arose from a conus branch separate to the RCA. No significant stenosis was visualised on CTCA. The T-wave changes on electrocardiogram and subtle subendocardial enhancement/fibrosis in the anterior wall on cardiac magnetic resonance imaging were deemed to be secondary to supply–demand ischaemia, particularly at the distal end of the RCA, where it supplied the left anterior descending artery territory. The patient was discharged on metoprolol 25 mg twice daily and her usual warfarin. Single RCA with absent LMCA is extremely rare with only few isolated cases in the literature. Use of CTCA in combination with coronary angiography was useful in defining this unusual anatomy.

Submillisievert imaging protocol using full reconstruction and advanced patient motion correction in 320-row area detector coronary CT angiography.

Radiation exposure remains a concern in the use of coronary CT angiography (CCTA). Full reconstruction (Full) and reconstruction using advanced patient motion correction (APMC) could obtain a lower radiation dose using low tube current scanning in a 320-row Area Detector CT (320-ADCT). The radiation dose for an imaging protocol using Full and APMC in daily practice was estimated. A total of 209 patients who underwent CCTA in 1 rotation scanning with 100 kv and adaptive iterative dose reduction 3D in 320-ADCT were enrolled. Imaging protocols were classified into 3 groups based on estimated slow filling time: (1) slow filling time ≥ 275 msec, Full with 30% of usual tube current (N = 43)(Full30%mA) (2) 206.3 msec ≤ slow filling time < 275msec, APMC with 50% of usual tube current (N = 48)(APMC50%mA); and (3) 137.5msec ≤ slow filling time < 206.3msec, Half reconstruction with usual tube current (N = 118)(Half100%mA). Radiation dose was estimated by the effective dose. The diagnostic accuracy of CCTA was compared with that of invasive coronary angiography in 28 patients. The effective doses of Full30%mA, APMC50%mA, and Half100%mA were 0.77 ± 0.31, 1.30 ± 0.85, and 1.98 ± 0.68, respectively. Of 28 patients, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value in vessel-based analyses were: Full30%mA, 66.7, 82.4, 80.0, 40.0, and 93.3%; APMC50%mA, 100.0, 80.0, 83.3, 50.05, and 100.0%; and Half100%mA, 90.9, 83.0, 86.3, 78.95, and 92.9%, respectively. An imaging protocol using Full30%mA and APMC50%mA was one of the methods how radiation dose could be reduced radiation dose maintained diagnostic accuracy compared to imaging using conventional Half100%mA.

Rural CTCA: Effectively Managing the Tyranny of Distance

Australian health care systems must service a sparse population across vast distances. Despite recent improvements, geographic isolation, health-literacy, income level, and the higher prevalence of cardiovascular risk factors in rural communities contribute to the persisting disparity between rural and urban populations [1Murphy G.K. McAlister F.A. Weir D.L. Tjosvold L. Eurich D.T. Cardiovascular medication utilization and adherence among adults living in rural and urban areas: a systematic review and meta-analysis.BMC Public Health. 2014; 14: 544Crossref PubMed Scopus (25) Google Scholar, 2Ranasinghe I. Turnbull F. Tonkin A. Clark R.A. Coffee N. Brieger D.B. Comparative effectiveness of population interventions to improve access to reperfusion for ST-segment-elevation myocardial infarction in Australia.Circulation: Cardiovascular Quality and Outcomes. 2012; 5: 429-436Crossref PubMed Scopus (24) Google Scholar]. Computed tomography coronary angiography (CTCA) and coronary artery calcium scoring (CACS) have not previously been described in a rural population. In this study of 1,492 patients undergoing CTCA in regional NSW, we examined the contribution of distance from cardiology services on the severity of coronary artery disease, measured by CACS, as well as time to percutaneous intervention (PCI). Our study captured all CTCAs performed in the Riverina since introduction of the service in 2012. Patients were excluded if they resided outside of the Murrumbidgee Local Health District or had undergone previous stents or CABG. Spearman's rank correlations demonstrated positive correlations between distance from cardiology services and CACS (rs = 0.082; n = 1472; p = -0.001) and distance and degree of stenosis on CTCA (rs = 0.055; n = 1450; p = 0.036). There was no correlation between distance and time to invasive angiography. Although patients residing further from cardiology services present with higher CACS, this has not translated into a delay of invasive angiography, nor an increase in adverse events. These data support the use of CTCA in rural areas as an effective tool for the investigation of CAD.

Diagnostic and Prognostic Benefits of CTCA Using the Updated NICE Guidance: An Analysis of the Scottish COmputed Tomography of the HEART (SCOT-HEART) trial

Objectives: To evaluate the diagnostic and prognostic benefits of computed tomography coronary angiography (CTCA) when employed in accordance with the updated UK National Institute for Health and Care Excellence (NICE) guidelines for the assessment of suspected stable angina. Methods: Post-hoc analysis of the Scottish COmputed Tomography of the HEART (SCOT-HEART) multicentre trial which randomised participants with suspected angina to standard care or CTCA. Patients were dichotomised based on symptoms and the resting electrocardiogram in accordance with the NICE definitions for possible angina and non-anginal presentations. The primary (diagnostic) endpoint was diagnostic certainty of angina at 6 weeks. The long-term prognostic endpoint comprised a composite of fatal and non-fatal myocardial infarction (MI). Results: 3,770 participants were randomised and follow-up was 3.2 years. CTCA increased diagnostic certainty. This benefit was greatest (pinteraction < 0.001) in those with possible angina (CTCA 34.9%, standard care 15.7%; RR 2.22, 95% CI 1.91 to 2.60, p < 0.001). This was attenuated in the non-anginal cohort (CTCA 32%, standard care 25.2%; RR 1.30, 95% CI 1.11 to 1.53, p = 0.002). CTCA reduced the likelihood of fatal or non-fatal MI in the cohort with possible angina from 3.2% to 1.9% (HR 0.58; 95% CI 0.34 to 0.99; p = 0.045). This reduction in clinical events was not statistically significant in the non-anginal cohort (HR 0.65; 95% CI 0.25 to 1.69; p = 0.379) (pinteraction = 0.836). Conclusions: The 2016 NICE guideline suitably identifies patients requiring further investigation of angina. Within this context, the use of CTCA is associated with greater diagnostic certainty and a reduced risk of myocardial infarction.