Juhani Knuuti, Haitham Ballo, Luis Eduardo Juarez-Orozco, Antti Saraste, Philippe Kolh, AnneWilhelmina Saskia Rutjes, Peter Ju¨ni, StephanWindecker, Jeroen J. Bax, and William Wijns


To determine the ranges of pre-test probability (PTP) of coronary artery disease (CAD) in which stress electrocardiogram (ECG), stress echocardiography, coronary computed tomography angiography (CCTA), single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance (CMR) can reclassify patients into a post-test probability that defines (>85%) or excludes (<15%) anatomically (defined by visual evaluation of invasive coronary angiography [ICA]) and functionally (defined by a fractional flow reserve [FFR] <_0.8) significant CAD.
A broad search in electronic databases until August 2017 was performed. Studies on the aforementioned techniques in >100 patients with stable CAD that utilized either ICA or ICA with FFR measurement as reference, were included. Study-level data was pooled using a hierarchical bivariate random-effects model and likelihood ratios were obtained for each technique. The PTP ranges for each technique to rule-in or rule-out significant CAD were defined. A total of 28 664 patients from 132 studies that used ICA as reference and 4131 from 23 studies using FFR, were analysed. Stress ECG can rule-in and rule-out anatomically significant CAD only when PTP is >_80% (76–83) and <_19% (15–25), respectively. Coronary computed tomography angiography is able to rule-in anatomic CAD at a PTP >_58% (45–70) and rule-out at a PTP <_80% (65–94). The corresponding PTP values for functionally significant CAD were >_75% (67–83) and <_57% (40–72) for CCTA, and >_71% (59–81) and <_27 (24–31) for ICA, demonstrating poorer performance of anatomic imaging against FFR. In contrast, functional imaging techniques (PET, stress CMR, and SPECT) are able to rule-in functionally significant CAD when PTP is >_46–59% and rule-out when PTP is <_34–57%.
The various diagnostic modalities have different optimal performance ranges for the detection of anatomically and functionally significant CAD. Stress ECG appears to have very limited diagnostic power. The selection of a diagnostic technique for any given patient to rule-in or rule-out CAD should be based on the optimal PTP range for each test and on the assumed reference standard.

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