Diagnostic Yield of Second-Line Functional Imaging After an Abnormal Coronary CTA: An Individual Patient-Data Meta-analysis.
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Authors
Rasmussen L.D.
Hoek R.
Westra J.
Soby J.H.
Maaniitty T.
Braathen A.T.
Saraste A.
Isaksen C.
Nissen L.
Petersen S.E.
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2026
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AIMS: Second-line functional imaging is recommended following an abnormal coronary computed tomography angiography (CCTA). However, evidence guiding the choice of imaging modality is limited. We assessed the diagnostic performance of second-line functional imaging using different invasive reference standard. METHODS AND RESULTS: We conducted an individual patient-data meta-analysis of seven prospective diagnostic studies including 1,410 patients (mean age 62+/-8.1 years, 67% male) with abnormal CCTA (>=50% diameter stenosis (DS)), who underwent second-line functional imaging tests (dobutamine stress ECHO, SPECT, CMR, and/or PET) followed by invasive angiography with fractional flow reserve (FFR) and quantitative coronary angiography (QCA). Haemodynamically obstructive coronary artery disease (CAD) was defined as invasive FFR 90% visual diameter stenosis (DS); anatomically severe CAD as >=70% DS by QCA.Pooled and per test, 904/1,906 (47.2 %) functional imaging tests had hemodynamically obstructive CAD, and 504/1,906 (26.3 %) functional imaging tests had anatomically severe CAD. In total, 730/1,906 (38.3%) functional imaging tests were abnormal. Pooled sensitivity and specificity were 63% and 84% for hemodynamically obstructive CAD, and 81% and 77% for anatomically severe CAD. Findings were generally stable across sex and age. More advances second-line functional imaging tests showed higher sensitivities, but lower specificities compared to less advanced techniques. CONCLUSION(S): Second-line functional imaging after an abnormal CCTA enables identification of patients with anatomically severe CAD. In contrast, moderate stenoses (<70% DS) with FFR <=0.80 do not consistently result in myocardial ischemia detectable by functional imaging tests. Substantial diagnostic accuracy differences were found between non-invasive diagnostic test which needs further investigation. Copyright © The Author(s) 2026. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site-for further information please contact
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European heart journal.Cardiovascular Imaging