CT coronary angiography guided treatment versus routine invasive coronary angiography in patients with non-ST elevation myocardial infarction: a systematic review and meta-analysis.
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Authors
Lee R.H.K.
Kam M.H.M.
Chatchalermwit P.
Weston C.
Oon G.R.
Moosa B.
Gray A.J.
Kelham M.
Jones D.A.
Wang K.L.
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2026
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Article
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Background Non-ST-segment-elevation myocardial infarction (NSTEMI) accounts for the majority of acute coronary syndrome presentations. Invasive coronary angiography (ICA) is recommended but challenging to deliver within guideline-recommended timeframes and unnecessary in patients without obstructive disease. CT coronary angiography (CTCA) offers a non-invasive alternative for lower-risk patients that may reduce procedural-related complications and optimise resource use by avoiding unnecessary ICA. Methods We conducted a systematic review and meta-analysis following Cochrane standards. Four databases were searched from January 2005 to March 2025. Eligible studies included adult patients with NSTEMI undergoing CTCA to guide management, with comparators of standard care (ICA-first strategies). Primary outcomes were ICA utilisation, composite cardiovascular events (myocardial infarction, cardiovascular and all-cause death) and diagnostic accuracy of CTCA versus ICA. Results From 12 058 records, eight studies met inclusion criteria; three randomised controlled trial (RCT) studies and five observational cohorts; total n=2700. Across two RCTs, a CTCA-first strategy did not significantly reduce ICA use (pooled relative risk (RR)=0.82 (0.55-1.22)). Evidence for composite clinical outcomes was heterogeneous: The Rapid Assessment of Potential Ischaemic Heart Disease with CTCA trial reported no difference in death or MI, whereas the trial, Computed Tomography Cardiac Angiography Before Invasive Coronary Angiography in Patients with Previous Bypass Surgery, observed reduced events at 1 year (RR=0.63 (0.43-0.94)). Pooled diagnostic accuracy for >50% stenosis from observational studies demonstrated high sensitivity (96.3%) and moderate specificity (79.6%), with high heterogeneity. Length of stay and patient satisfaction were similar or improved with CTCA-first strategies, though cost-effectiveness data were limited. Overall evidence quality ranged from moderate (RCTs) to low (observational studies). Conclusions CTCA demonstrates excellent diagnostic accuracy and may reduce complications while maintaining clinical outcomes in patients with NSTEMI. Current evidence does not show consistent reductions in ICA use or major adverse events. Larger trials are needed to clarify its role in NSTEMI management pathways. Copyright © Author(s) (or their employer(s)) 2026.
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Open Heart
Volume
13