STABLE CHEST PAIN: CTA ± FFR-CT VERSUS FUNCTIONAL TESTING AND THE IMPACT ON UNNECESSARY INVASIVE ANGIOGRAPHY

Abstract

DOI: https://doi.org/10.46296/gt.v8i16.0313

Abstract

Stable chest pain requires diagnostic pathways that minimize invasive coronary angiography without obstructive disease and optimize outcomes. This critical review appraises recent evidence comparing an anatomic strategy centered on coronary computed tomographic angiography—with selective use of computed-tomography–derived fractional flow reserve—versus functional ischemia testing (stress echocardiography, myocardial perfusion scintigraphy, positron-emission tomography, and stress cardiac magnetic resonance). We prioritized randomized trials, meta-analyses, comparative cohorts, and guidelines since 2016, focusing on invasive angiography without significant stenosis, major adverse cardiovascular events, appropriate revascularization, downstream testing, radiation, contrast exposure, and costs. Overall, the anatomic approach lowers the rate of “negative” catheterizations, concentrates invasive procedures on lesions with hemodynamic significance, and enhances prevention by uncovering non-obstructive coronary disease; this combination is associated with fewer myocardial infarctions at intermediate follow-up. Functional imaging remains valuable when computed tomography underperforms (extensive calcification, arrhythmias, severe obesity, prior revascularization, kidney dysfunction) and to quantify ischemic burden or diagnose microvascular angina. Both strategies are safe; computed-tomography–derived fractional flow reserve adds no additional radiation. A pragmatic algorithm is proposed: base test selection on pretest probability and coronary calcium. Use computed tomographic angiography as first-line in low-to-intermediate risk, add computed-tomography–derived fractional flow reserve for intermediate stenoses, and prioritize functional imaging when anatomy is poorly evaluable or clinical context demands it. This integrated approach reduces unnecessary invasive angiography without compromising clinical outcomes.

Keywords: Angiography, coronary computed tomography, myocardial ischemia, fractional flow reserve, stress testing, cardiac magnetic resonance imaging, positron emission tomography.