Utility of Coronary CT Angiography Versus Functional Stress Testing in Patients With Stable Chest Pain: A Systematic Review

Abstract Stable chest pain is a common presentation requiring accurate diagnostic strategies to identify coronary artery disease (CAD) while minimizing risks. This systematic review compares the utility of coronary computed tomography angiography (CCTA) versus functional stress testing (e.g., exercise electrocardiography, stress echocardiography, nuclear perfusion imaging) in patients with stable chest pain. Following PRISMA guidelines, we searched PubMed, EMBASE, and Cochrane databases for randomized controlled trials (RCTs) and meta-analyses published through July 2025. Included studies evaluated diagnostic accuracy, clinical outcomes (e.g., myocardial infarction [MI], death, revascularization), and resource utilization. From 1,280 screened records, 18 studies (including 6 RCTs and 5 meta-analyses) involving over 30,000 patients were analyzed. CCTA demonstrated superior sensitivity (94.6%; 95% CI, 92.7-96.0) and specificity (76.3%; 95% CI, 72.2-80.0) for obstructive CAD compared with functional testing (sensitivity, 54.9-72.9%; specificity, 44.9-60.9%). CCTA was associated with reduced MI incidence (RR, 0.69; 95% CI, 0.49-0.98) but increased initial invasive procedures. Guidelines endorse CCTA as first-line for intermediate-risk patients. CCTA offers better prognostic value and efficiency compared with functional testing.