Faster and More Affordable Heart Testing Could Transform How Doctors Diagnose Coronary Artery Disease

Cardiovascular disease continues to be one of the leading causes of death worldwide, and diagnosing heart problems early and accurately remains a major challenge for healthcare systems. A newly published international expert consensus review in The Lancet sheds light on how changes in diagnostic strategies—particularly the wider use of CT coronary angiography (CTCA)—could significantly improve outcomes for patients with suspected chronic coronary artery disease while also reducing costs and unnecessary procedures.

The review, titled Contemporary, non-invasive imaging diagnosis of chronic coronary artery disease, brings together insights from global experts and highlights why non-invasive imaging deserves a more central role in modern cardiology. One of the key contributors to this work is Dr. Partho P. Sengupta, a cardiology expert from Rutgers Robert Wood Johnson Medical School and chief of cardiology at Robert Wood Johnson University Hospital.

At the heart of the discussion is a simple but powerful idea: using the right test for the right patient at the right time can save lives.

Understanding Pre-Test Probability and Why It Matters

When patients arrive with symptoms that could suggest coronary artery disease—such as chest pain, shortness of breath, or unexplained fatigue—doctors estimate something called pre-test probability (PTP). This is essentially an assessment of how likely it is that a patient actually has coronary artery disease before any imaging or invasive testing is done.

Patients are typically categorized into low, intermediate, or high PTP groups. Current clinical guidelines generally discourage routine testing for patients with a very low PTP, often defined as less than 5%, because the likelihood of finding significant disease is considered minimal.

However, the Lancet review challenges parts of this long-standing approach, especially when it comes to patients in the low to intermediate PTP range.

Why CT Coronary Angiography Is Gaining Attention

CT coronary angiography is a non-invasive imaging test that uses advanced CT scanning technology to visualize the coronary arteries. Unlike traditional stress tests, CTCA provides a detailed anatomical view of the arteries, allowing doctors to see plaque buildup and narrowing directly.

One of the strongest arguments in favor of CTCA is its high negative predictive value. In practical terms, this means that when a CTCA scan comes back negative, doctors can be highly confident that the patient does not have significant coronary artery blockages.

According to the experts behind the Lancet review, using CTCA in patients with low to intermediate pre-test probability can lead to more accurate diagnoses, fewer missed cases of disease, and faster reassurance for patients who do not have dangerous blockages. This is especially important because undiagnosed or delayed diagnosis of coronary artery disease can lead to heart attacks and other life-threatening complications.

Limitations of CTCA in High-Risk Patients

While CTCA shows clear advantages for certain patient groups, the review is careful to point out its limitations. In patients with a high pre-test probability, CTCA can sometimes overestimate the severity of artery narrowing.

A major reason for this is heavy coronary artery calcification. Calcium deposits in the artery walls can interfere with CT imaging, making blockages appear more severe than they actually are. This can result in false-positive findings, which may lead to unnecessary follow-up tests or invasive procedures.

Because of this, the experts emphasize that CTCA should not be used in isolation for high-risk patients. Instead, it should be part of a stepwise diagnostic strategy.

The Role of Additional Testing Like FFR and Cardiac Catheterization

When CTCA results are unclear or suggest severe disease—particularly in high-risk individuals—additional testing may be needed. One commonly used option is fractional flow reserve (FFR).

FFR is a minimally invasive procedure that measures how much blood flow is actually being restricted by a coronary artery narrowing. It helps determine whether a blockage seen on imaging is truly limiting blood supply to the heart muscle and therefore requires treatment.

In some cases, doctors may still need to rely on cardiac catheterization, an invasive procedure that directly visualizes the coronary arteries and allows for interventions such as stent placement if necessary. The key message from the review is not to eliminate these procedures, but to use them more selectively.

Why Accessibility and Infrastructure Remain Major Challenges

Despite the growing evidence supporting CTCA, the technology is not yet widely available at many medical facilities. High-quality CT scanners, specialized software, and trained personnel are required to perform and interpret CTCA accurately.

This lack of access means that many patients still undergo older testing methods that may be less precise or more invasive. The review suggests that investing in CTCA infrastructure could ultimately reduce overall healthcare costs by minimizing unnecessary invasive procedures and hospital stays.

Broader Context: Non-Invasive Imaging Options for Coronary Disease

The Lancet review doesn’t focus on CTCA alone. It provides a comprehensive overview of several non-invasive imaging techniques, including:

• Stress echocardiography, which evaluates heart function under physical or pharmacological stress
• Nuclear imaging techniques such as SPECT and PET scans, which assess blood flow to the heart muscle
• Cardiac magnetic resonance imaging (CMR), which offers high-resolution images and functional data without radiation

Each modality has its strengths and weaknesses, and the experts stress that no single test is ideal for every patient. The future of cardiology lies in tailoring diagnostic strategies based on individual risk profiles, symptoms, and available resources.

How This Could Change Clinical Guidelines

One of the most important implications of this consensus review is its potential impact on clinical practice guidelines. While current guidelines often recommend against testing in very low-risk patients, the evidence supporting CTCA’s reliability may lead to more nuanced recommendations.

For patients with borderline symptoms or uncertain risk levels, CTCA could serve as an efficient gatekeeper test—quickly ruling out serious disease or identifying patients who truly need further evaluation.

A Shift Toward Smarter, Patient-Centered Care

Overall, the message from this international expert review is clear: non-invasive imaging is reshaping how doctors diagnose chronic coronary artery disease. By using CT coronary angiography more strategically—especially in low to intermediate risk patients—healthcare providers can improve diagnostic accuracy, reduce unnecessary procedures, and potentially save lives.

As technology continues to advance and access improves, CTCA and other non-invasive imaging tools are likely to become even more central to everyday cardiology practice.

Research Reference
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)01586-7