Coronary Computed Tomographic Angiography for Suspected Stable Coronary Artery Disease: Gap Between the 2013 European Society of Cardiology Guideline Recommendations and Clinical Practice

IntRoductIon Coronary computed tomographic angiography (CCTA) as a noninvasive diagnostic technique for the evaluation of coronary anatomy is widely used clinically. Its advantages include high sensitivity and specificity for the diagnosis of present of coronary artery lesions and lesion characteristics, short scan time, low patient radiation exposure, and acceptable to patients. The sensitivity and specificity of CCTA for diagnosing coronary artery disease are 83%–100% and 70%–80% at patient level or 83%–97% and 93%–100% at vessel level. It can be proceeded in out‐patient clinic for the most of the candidates. In high patient volume hospitals and most county hospitals, even more multi‐slice computed tomography scanners are used for screening the coronary artery disease (CAD), but there is no stress testing equipment for functional evaluation of CAD before CCTA. The rule of CCTA in management of patients with symptoms suspicious for CAD comparing to well‐established other noninvasive stress techniques including stress exercise electrocardiogram (ECG), single photon emission computed tomography (SPECT), and stress cardiac echocardiography is still not well‐studied in different patients population. Assessment of patients with typical of stable or atypical angina generally follows the guidelines and established stepwise approach which based on evidence of clinical studies.[1‐3] The first step for the approach of CAD includes careful history taking, basic physical examination, routine ECG, and risk factors assessment to define the likelihood of CAD. Depending on the risk factors, patients are classified into subgroups of low, intermediate, and high pretest likelihood probability, and further noninvasive and invasive evaluation methods are referred. Patients with positive result of most common used stress ECG are only 41% likely to have obstructive coronary heart disease defined by invasive coronary angiography.[4] This is why stress testing is less referred compared to CCTA for the initial test. Some of the exercise ECG results are not interpretable.