Systematic review, meta-analysis and economic modelling of ...
Systematic review, meta-analysis and economic modelling of ... Systematic review, meta-analysis and economic modelling of ...
Assessment of diagnostic and prognostic accuracyUnique citations retrieved by search ofelectronic databases(n = 2667)Citations included from studiespublished after the searches werecomplete(n = 12)Expert identified (n = 10)Post-search citation (n = 2)Abstracts potentially relevant for dataextraction, full paper acquired(n = 173)Abstracts excluded after screeningof titles and abstracts(n = 2494)Excluded studies not relevant fordata extraction(n = 144)Papers satisfying inclusion criteria(n = 29)CTCA papers(n = 16)ExECG papers(n = 13)Diagnosis(n = 8)Prognosis(n = 8)Prognosis(n = 13)FIGURE 26 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart CTCA and ETTreview. Ex ECG, exercise ECG.due to calcification, movement or heart rate, which may be more common or more variable in patientspresenting with acute symptoms.Prognostic studies of computed tomographic coronary angiographyTable 26 shows the characteristics of the seven prognostic studies of CTCA and one study of CAC scoring.Three of the cohorts (four studies) were compared with control groups in a trial, 131–134 whereas theothers were single cohort studies. All of the CTCA studies used 64-slice CT. The cohorts were generallylarger (n = 30–588) and the mean age (46–56 years) younger than the diagnostic studies. This reflectsthe inclusion criteria that generally selected low- to intermediate-risk patients. Those with ECG changesand positive biomarkers were usually explicitly excluded. The diagnostic classification for CTCA eitherdichotomised scans into obstructive (> 50% stenosis) or non-obstructive (< 50%), or limited positive scansto those with stenosis > 70% and used an intermediate category for stenosis of 26–69% or 50–70%.Duration of follow-up ranged from 30 days to 2 years. Definitions of MACEs varied, with most studiesincluding revascularisation in the definition but two limiting MACEs to death and MI, 133 or death, MI andunstable angina. 131 Most cases of MACEs were revascularisation rather than death or MI.Table 27 shows the quality assessment of the CTCA and CAC scoring prognostic studies. All the studiesdescribed patient characteristics in terms of age and sex, but the description of times to presentation wasinconsistent. All but one study 134 defined MACEs in their methods section. In all studies the identificationand definition of MACEs was independent of the index test and, in accordance with the inclusion criteria,MACEs were reported for at least 80% of the cohort. However, only one study 136 used multivariate68NIHR Journals Library
DOI: 10.3310/hta17010 Health Technology Assessment 2013 Vol. 17 No. 1TABLE 25 Characteristics of diagnostic studies of CTCAPaper TechnologyBetablockernMean age (years)CTCA diagnosticand sex Inclusion criteria Exclusion criteria a criteriaICA diagnosticcriteriaCasciani 2008 123 16 slice Yes 37 62; 29/37 (78%)maleChest pain compatiblewith myocardialischaemiaDiagnostic ECG changes, elevatedbiomarkers> 50% stenosis > 50% stenosisColes 2007 124 16 slice Yes 113 62; 78/113 (65%)maleAcute chest painsuggesting ACS within24 hoursSTEMI, haemodynamicallyunstable≥ 50% stenosis ≥ 50% stenosisGhersin 2006 125 16 slice No 66 57; 52/66 (79%)maleAcute chest pain Arrhythmia ≥ 50% stenosis ≥ 50% stenosisHenneman 2008 126 64 slice Yes 40 57; 26/40 (65%)maleSuspected ACS STEMI 50% stenosis +calcium score≥ 50% stenosisMinocha 2006 127 16 slice Unclear 70 53; 63/70 (90%)maleAcute chest pain Definite ACS, previous CABG > 50% stenosis > 50% stenosisOlivetti 2006 128 16 slice Yes 31 59; 19/31 (61%)maleMedium/low-risk chestpain within 24 hoursArrhythmia, previous cardiacdisease> 50% stenosis > 50% stenosisSato 2005 129 4 slice Yes 34 56; 29/31 (93%)male> 30 minutes of chestpain within 24 hoursDiagnostic ECG changes, elevatedbiomarkers≥ 75% stenosis ≥ 75% stenosisTsai 2007 130 Unclear Yes 78 61; 55/78 (71%)maleLow-risk suspected ACS Prolonged symptoms, age> 70 years, diagnostic ECGchanges, positive biomarkers,previous MI or CABG≥ 50% stenosis ≥ 50% stenosisCABG, coronary artery bypass graft.a Other than contraindications to CTCA or ICA.© Queen’s Printer and Controller of HMSO 2013. This work was produced by Goodacre et al. under the terms of a commissioning contract issued by the Secretary of Statefor Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journalsprovided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should beaddressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton SciencePark, Southampton SO16 7NS, UK.69
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DOI: 10.3310/hta17010 Health Technology Assessment 2013 Vol. 17 No. 1TABLE 25 Characteristics <strong>of</strong> diagnostic studies <strong>of</strong> CTCAPaper TechnologyBetablockernMean age (years)CTCA diagnostic<strong>and</strong> sex Inclusion criteria Exclusion criteria a criteriaICA diagnosticcriteriaCasciani 2008 123 16 slice Yes 37 62; 29/37 (78%)maleChest pain compatiblewith myocardialischaemiaDiagnostic ECG changes, elevatedbiomarkers> 50% stenosis > 50% stenosisColes 2007 124 16 slice Yes 113 62; 78/113 (65%)maleAcute chest painsuggesting ACS within24 hoursSTEMI, haemodynamicallyunstable≥ 50% stenosis ≥ 50% stenosisGhersin 2006 125 16 slice No 66 57; 52/66 (79%)maleAcute chest pain Arrhythmia ≥ 50% stenosis ≥ 50% stenosisHenneman 2008 126 64 slice Yes 40 57; 26/40 (65%)maleSuspected ACS STEMI 50% stenosis +calcium score≥ 50% stenosisMinocha 2006 127 16 slice Unclear 70 53; 63/70 (90%)maleAcute chest pain Definite ACS, previous CABG > 50% stenosis > 50% stenosisOlivetti 2006 128 16 slice Yes 31 59; 19/31 (61%)maleMedium/low-risk chestpain within 24 hoursArrhythmia, previous cardiacdisease> 50% stenosis > 50% stenosisSato 2005 129 4 slice Yes 34 56; 29/31 (93%)male> 30 minutes <strong>of</strong> chestpain within 24 hoursDiagnostic ECG changes, elevatedbiomarkers≥ 75% stenosis ≥ 75% stenosisTsai 2007 130 Unclear Yes 78 61; 55/78 (71%)maleLow-risk suspected ACS Prolonged symptoms, age> 70 years, diagnostic ECGchanges, positive biomarkers,previous MI or CABG≥ 50% stenosis ≥ 50% stenosisCABG, coronary artery bypass graft.a Other than contraindications to CTCA or ICA.© Queen’s Printer <strong>and</strong> Controller <strong>of</strong> HMSO 2013. This work was produced by Goodacre et al. under the terms <strong>of</strong> a commissioning contract issued by the Secretary <strong>of</strong> Statefor Health. This issue may be freely reproduced for the purposes <strong>of</strong> private research <strong>and</strong> study <strong>and</strong> extracts (or indeed, the full report) may be included in pr<strong>of</strong>essional journalsprovided that suitable acknowledgement is made <strong>and</strong> the reproduction is not associated with any form <strong>of</strong> advertising. Applications for commercial reproduction should beaddressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials <strong>and</strong> Studies Coordinating Centre, Alpha House, University <strong>of</strong> Southampton SciencePark, Southampton SO16 7NS, UK.69
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