Primacy of coronary CT angiography as the gatekeeper for the cardiac catheterization laboratory.

Determining the underlying etiology of chest pain remains a mainstay of modern cardiological practice and is focused on identifying coronary artery disease to improve both symptoms and prognosis. In the current age of multi-modality imaging, the expanding repertoire of tests has subjected clinicians to a tyranny of choices. In whom should we perform further investigations? What non-invasive modality should be used? Which test is the best gatekeeper for invasive coronary angiography? In this week's American Heart Journal, Houssany-Pissot and colleagues present real-world data from a large French cohort of patients who present with suspected stable coronary artery disease undergoing invasive coronary angiography. Their findings demonstrate that compared to functional testing, coronary computed tomography angiography is associated with fewer normal invasive coronary angiograms and more patients with actionable disease. Moreover, this was apparent irrespective of the pre-test probability of obstructive coronary artery disease. The consistency of this study with data from randomised trials and observational registries leads us to agree that computed tomography has primacy as gatekeeper for the cardiac catheter laboratory irrespective of the level of pre-test probability. This latest addition to the growing and large body of evidence does beg the question of why guidelines do not now recommend CCTA as the first line test of choice for the non-invasive investigation of all patients with stable coronary artery disease?