EVIDENCE-BASED ANSWER
MULTIDETECTOR COMPUTED TOMOGRAPHY (MDCT) may be the most sensitive and specific noninvasive diagnostic test for women with suspected coronary artery disease (CAD) (strength of recommendation [SOR]: A, multiple prospective cohort studies). However, stress echocardiography and nuclear medicine perfusion testing are still the best well-tested and readily available alternatives in light of the newness of MDCT and concerns regarding its use (SOR: A, meta-analysis and cohort studies).
Standard exercise treadmill testing (ETT) doesn’t adequately exclude or confirm CAD in women (SOR: A, multiple prospective cohort studies).
Evidence summary
A prospective cohort study of 96 symptomatic women, average age 55.8 years, who were referred for coronary angiography, examined the accuracy of ETT compared with the gold standard of conventional coronary angiography.1 Sensitivity, specificity, and diagnostic accuracy were comparatively low for ETT (TABLE). The authors concluded that ETT has limited diagnostic value in women with suspected CAD. Myocardial perfusion imaging (MPI) is more predictive of CAD, as a prospective cohort study of 68 symptomatic women demonstrated.2
TABLE
Suspect CAD in your female patient? Here’s how various tests compare with coronary angiography
| Test | Number of subjects | Sensitivity (95% CI) | Specificity (95% CI) | LR+(95% CI) | LR-(95% CI) | Diagnostic accuracy* |
|---|---|---|---|---|---|---|
| ETT1 | 96 | 31% (17%-49%) | 52% (40%-64%) | 0.65 (0.36-1.18) | 1.32 (0.95-1.84) | 46% |
| ETT2 | 68 | 33% (21%-48%) | 74% (53%-87%) | 1.28 (0.57-2.81) | 0.90 (0.66-1.24) | 47% |
| MPI2 | 68 | 80% (66%-89%) | 78% (58%-90%) | 3.68 (1.67-8.10) | 0.26 (0.14-0.48) | 79% |
| DSE3 | 901 | 72% (67%-76%) | 88% (85%-91%) | 5.97 (4.64-7.68) | 0.32 (0.28-0.37) | 80% |
| 64-slice MDCT4 | 123 | 99% (93%-100%) | 75% (62%-84%) | 3.91 (2.54-6.01) | 0.01 (0.00-0.17) | 88% |
| 40-slice MDCT5 | 21 | 73% (51%-96%) | 83% (53%-100%) | 4.39 (0.72-27.02) | 0.32 (0.13-0.80) | 76% |
| 16-slice MDCT6 | 70 | 89% (67%-97%) | 88% (77%-95%) | 7.61 (3.53-16.38) | 0.12 (0.03-0.44) | 89% |
| CAD, coronary artery disease; CI, confidence interval; DSE, dobutamine stress echocardiography; ETT, exercise treadmill testing; LR+, positive likelihood ratio; LR-, negative likelihood ratio; MDCT, multidetector computed tomography; MPI, myocardial perfusion imaging. *Diagnostic accuracy=true positive + true negative out of total number of subjects. | ||||||
A meta-analysis of 14 studies that compared dobutamine stress echocardiography with conventional coronary angiography in 901 women found an overall sensitivity of 72% and specificity of 88% for echocardiography.3
MDCT has high accuracy, but also some limitations
Three prospective cohort studies compared 64-, 40-, and 16-slice MDCT with conventional coronary angiography in 123, 21, and 70 symptomatic women, respectively, and each study demonstrated high sensitivity and specificity for MDCT in diagnosing CAD.4-6 Diagnostic accuracy was similar among slice techniques. The studies had multiple limitations, including location (potential population bias), patient symptoms, and setting (potential referral bias).