Initial noninvasive diagnostic testing in patients with low-risk acute coronary syndrome resulted in fewer recommendations for invasive cardiovascular testing compared with noninvasive anatomical testing, according to a study published in the BMJ.

George CM Siontis, MD, PhD, of the Department of Cardiology at Bern University Hospital in Switzerland, and colleagues conducted a systematic review and meta-analysis observing variations in downstream testing, coronary artery revascularization, and clinical effects after noninvasive coronary artery disease diagnostic techniques.

Patients who were eligible included those with symptoms suggesting the presence of low-risk acute coronary syndrome (n= 11,329) or stable coronary artery disease (n= 22, 062) in 18 trials.

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Stress echocardiography (odds ratio [OR], 0.28), cardiovascular magnetic resonance (OR, 0.32), and exercise electrocardiograms (OR, 0.53) reduced recommendations for invasive coronary angiography in patients with low-risk acute coronary syndrome.

Single photon emission computed tomography-myocardial perfusion imaging (OR, 0.24) and stress echocardiography (OR, 0.57) both yielded less downstream testing compared with coronary computed tomographic angiography for patients with suspected stable coronary artery disease.

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No effects were reported for altered myocardial infarction risks for either patient group.

“Diagnostic tests are critical components of an effective healthcare system,” the authors wrote. “Diagnostic randomized controlled trials should become the default evaluation tool for new imaging modalities and clinical outcomes.”


  1. Siontis GCM, Mavridis D, Greenwood JP, et al. Outcomes of non-invasive diagnostic modalities for the detection of coronary artery disease: Network meta-analysis of diagnostic randomized controlled trials. BMJ. 2018 Feb 21. doi: 10.1136/bmj.k504