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Assessment of diagnostic and prognostic accuracyTABLE 26 Characteristics of prognostic studies of CTCA and CAC scoringPaper Technology Beta-blocker n a and sexAge (years)Goldstein 64-slice CTCA Yes 99 48, 42/992007 131 (43%) maleHollander 64-slice CTCA Yes 588 46, 193/5882009 132 (40%) maleHollander 64-slice CTCA Yes 568 47, 252/5682009 133 (44%) maleLaudon CT CAC2010 151 scoringNo 263 48, 159/263(60%) maleMiller 64-slice CTCA Yes 30 51, 13/302011 134 (43%) maleRubinshtein 64-slice CTCA Yes 58 56, 21/582007 135 (64%) maleSchlett 64-slice CTCA Yes 368 53, 226/3682011 136 (61%) maleShuman 64-slice CTCA Yes 81 55, 49/812010 137 (60%) maleTIMI, thrombolysis In myocardial infarction.a Number receiving CTCA.b Other than contraindications to CTCA.InclusionDiagnosticcriteria Exclusion criteria b criteria for CTCADuration offollow-up MACELow-risk chestpain within12 hoursDiagnostic ECG changes,known CAD, positivebiomarkers> 70% = positive< 26% = negative26–70% = inter6 months Death, MI,revascularisationLow-risk chestpainComorbidity, knowncardiac disease, cocaineuse≥ 70% = positive< 50% = negative50–69% = inter1 year Cardiovascular death,MILow-risk chestpainComorbidity, knowncardiac disease, cocaineuse≥ 70% = positive< 50% = negative50–69% = inter30 days Cardiac death, MI,revascularisation, strokeand hospitalisation foranginaLow-/intermediateriskchest painIschaemic ECG,elevated biomarkers,haemodynamicallyunstableCalcium score>0 30 days,1 + 5 yearsMI, PCI, CABG, deathLow-/intermediateriskchest painwithin 12 hoursDiagnostic ECG changes,positive biomarkers,needing hospitaladmissionNormal, nonobstructive,obstructive90 days MI, death, unplannedrevascularisationIntermediaterisksuspectedACSDiagnostic ECG changes,positive biomarkers,comorbidities≥ 50% stenosis 15 months Death, MI, PCI, CABG> 5 minutesof chest painwithin 24 hoursAbnormal ECG, elevatedtroponin> 50% stenosis 2 years Not statedLow-/moderateriskchest painDiagnostic ECG changes,positive biomarkers, TIMIscore of > 4, knowncardiac disease≥ 50% stenosis 3, 6, 12 months Cardiac death, MI,revascularisation72NIHR Journals Library
DOI: 10.3310/hta17010 Health Technology Assessment 2013 Vol. 17 No. 1analysis to determine if CTCA provided additional prognostic value beyond routine assessment with ECGand biomarkers.Table 28 summarises the results of the prognostic studies of CTCA. It was not always clear whetherpatients with positive CTCA had been followed up and whether there had been any events in thesepatients. MACE rates were generally very low in patients with a negative CTCA. The only adverse event in apatient with negative CTCA was a death in the long-term follow-up cohort of Hollander et al. 132 However,these low event rates may reflect selection of low-risk patients rather than accurate risk stratificationby CTCA. Most of the events reported in patients with positive CTCA findings were process events [i.e.percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG)], which in an unblindedstudy may simply reflect physicians acting upon CTCA findings. No patient with positive or intermediateTABLE 27 Quality assessment of CTCA and CAC scoring prognostic studiesStudy Q1 Q2 Q3 Q4 Q5 Q6 Q7Goldstein 2007 131 Y Y Y Y Y N NHollander 2009 132 N Y Y Y Y N NHollander 2009 133 N Y Y Y Y N NLaudon 2010 151 N Y Y Y Y N NMiller 2011 134 Y Y N Y Y N NRubinshtein 2007 135 N Y Y Y Y N NSchlett 2011 136 Y Y Y Y Y Y YShuman 2010 137 N Y Y Y Y N NN, no; U, unclear; Y, yes.Questions:Q1 Are inclusion criteria defined?Q2 Are characteristics described (age and sex)?Q3 Is a MACE defined in the methods section?Q4 Is a MACE identification and definition independent of the index test?Q5 Is a MACE outcome recorded for at least 80% of the cohort from baseline episode?Q6 Was a multivariate analysis undertaken?Q7 Was troponin measured and included in the multivariate analysis?TABLE 28 Outcomes summary for prognostic studies of CTCAPaper Positive CTCA a CTCA aIntermediateNegative CTCA aGoldstein 2007 131 0/8 0/24 0/67Hollander 2009 132 NR NR 1/481 (death)Hollander 2009 133 0/13 0/41 0/508Shuman 2010 137 NR NR 0/70Rubinshtein 2007 135 13/23 (two MI, eight PCI, three CABG) 1/20 (PCI) 0/15Miller 2011 134 0/18 – 0/10Schlett 2011 136 20/68 b 5/117 b 0/183a See Table 25 for definitions.b The 25 MACEs included 12 MIs, 23 revascularisations and no cardiac deaths.© 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.73
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ContentsAppendix 5 Expected discoun
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BackgroundTABLE 1 Hospital admissio
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Background2. investigation of the c
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BackgroundComputed tomographic coro
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Research questionsiii. the diagnost
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Assessment of diagnostic and progno
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Appendix 923. Westwood ME, Whiting
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