Key result
Negative non-invasive cardiac investigations convey an excellent prognosis, with pooled annual event rates of MI and cardiac death ranging from 0.32% for CCTA to 1.66% for SE (P<0.001).
Why the study?
Do different non-invasive cardiac investigations have different prognostic values after a negative test result in patients with suspected or known CAD?
Meta-Analysis (n=122,721)
Do different non-invasive cardiac investigations have different prognostic values after a negative test result in patients with suspected or known CAD?
p-value: p=<0.001
A negative result on any non-invasive cardiac investigation conveys an excellent prognosis, with apparent differences between modalities largely explained by variations in baseline population risk.
Clinicians may confidently defer invasive testing after negative results; confirms baseline risk largely explains modality differences in prognosis.
AIMS: To compare the prognostic value of negative non-invasive cardiac investigations (coronary computed tomographic angiography [CCTA], cardiovascular magnetic resonance [CMR], exercise electrocardiographic testing [EET], positron emission tomography [PET], stress-echocardiography [SE], and single-photon emission tomography [SPECT]) in patients with suspected or known coronary artery disease (CAD) and to explore the effect of adjustment for population event risk and presence of CAD. METHODS AND RESULTS: MEDLINE/PubMed database, EMBASE and Cochrane Library were searched from January-1990 to April-2015 for studies reporting annual event rates (AER) of myocardial infarction (MI) and cardiac death. Pooled estimates of AERs were calculated using a DerSimonian and Laird random-effects model. Multivariable linear meta-regression analysis was performed to compare the AER after a negative test result between modalities and to adjust for population event risk and proportion of patients with CAD. In 165 studies (122,721 patients), pooled AERs after negative test results differed significantly between modalities ranging from 0.32% for CCTA to 1.66% for SE, P < 0.001. However, the AER after a negative test result was positively correlated (r = 0.726, P < 0.001) with population event risk. Adjusting for population event risk and proportion of patients with CAD resulted in more similar event rates after a negative test result. CONCLUSION: This meta-analysis is the first study comparing the prognostic value of all available non-invasive cardiac investigations. Outcome differences between modalities after a negative test result are profoundly influenced by large variations in population event risk and a negative test result for all modalities conveys an excellent prognosis for patients with suspected or known CAD.
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Smulders et al. (2017) conducted a meta-analysis in suspected or known coronary artery disease (n=122,721). Negative non-invasive cardiac investigations (CCTA, CMR, EET, PET, SE, SPECT) vs. Between modalities was evaluated on Annual event rates (AER) of myocardial infarction (MI) and cardiac death (p=<0.001). Negative non-invasive cardiac investigations convey an excellent prognosis, with pooled annual event rates of MI and cardiac death ranging from 0.32% for CCTA to 1.66% for SE (P<0.001).
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