Comparative safety and effectiveness of coronary computed tomography: Systematic review and meta-analysis including 11 randomized controlled trials and 19,957 patients

Background/objectives The clinical approach to suspected or established coronary artery disease (CAD) has been revolutionized in the last few decades by coronary computed tomography (coroCT). Yet, uncertainty persists on its comparative diagnostic and clinical effectiveness. We conducted a systematic review on randomized controlled trials (RCTs) of coroCT. Methods We searched RCTs in PubMed and The Cochrane Library, extracting as outcomes of interest long-term rates of death, myocardial infarction, revascularization, and invasive coronary angiography. Effects were estimated with risk ratios (RR) and 95% confidence intervals. Results A total of 11 trials were included, with 19,957 patients followed for a median of 6 months. One trial focused on screening, 3 on stable CAD, and 7 on acute CAD. Meta-analysis showed that coroCT was associated with a trend toward fewer deaths or myocardial infarctions (RR = 0.84 [0.70–1.01]) whereas no significant difference was found for the risk of death (RR = 0.91 [0.71–1.18]). Conversely, the risk of myocardial infarction tended to be lower with coroCT at the overall analysis (RR = 0.77 [0.59–1.02]), and this effect reached statistical significance in studies focusing on subjects with stable CAD (RR = 0.69 [0.49–0.99]). These potential benefits were offset (or mediated) by a significant albeit modest increase in the need for invasive angiography (RR = 1.36 [1.08–1.72]), and ensuing coronary revascularization (RR = 1.76 [1.29–2.40]). Conclusions According to the current evidence base, coroCT is associated with an increased usage of invasive angiography and coronary revascularization when compared to standard of care, with possible benefits on nonfatal myocardial infarction, but without significant benefits on death or the composite of death or myocardial infarction.