Coronary artery disease (CAD), one of the leading causes of death worldwide, involves the narrowing of coronary arteries due to atherosclerosis, resulting in insufficient blood flow to the heart muscle. This can cause symptoms such as chest pain and angina pectoris. Accurate diagnosis is crucial for the effective management of chronic CAD, with functional diagnostic tests like stress echocardiography or exercise ECG detecting the impact of narrow vessels on myocardial perfusion. Morphological tests such as coronary computed tomography angiography (CCTA) and invasive coronary angiography (ICA) are used to identify stenoses, with ICA being the gold standard for diagnosing chronic CAD.

When results are inconclusive, these tests may be supplemented with functional measurements, either invasively as part of ICA or through CT as part of CCTA. Despite the recommendation against ICA in patients with low to moderate pre-test CAD probability, its usage has increased, with approximately 30% of ICAs not finding any pathological issues. Now, a study to evaluate the benefits and potential harms of CCTA in patients with suspected CAD following initial diagnostic tests has shown that CCTA can reduce the need for more invasive diagnostic procedures. However, there are risks associated with CCTA, especially when followed by additional CT-based tests.

According to the findings of the final report submitted by the Institute for Quality and Efficiency in Health Care (IQWiG, Köln, Germany), CCTA offers significant benefits as an alternative to traditional tests for diagnosing chronic CAD, helping to determine the need for invasive tests. Compared with functional diagnostic tests and direct comparison with ICA, CCTA presents advantages by potentially replacing the more invasive ICA and demonstrating some improvements in treatment outcomes. Nonetheless, the strategy of employing CCTA followed by CT-based functional assessments did not show additional benefits and was associated with increased risks and procedural complications. 

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