The problem of intact coronary arteries: what non-invasive tests can solve it?

Abstract

Coronary artery disease (CAD) currently occupies a leading position in the structure of cardiovascular mortality and morbidity, which causes increased attention to its timely diagnosis. Despite a sufficient number of different non-invasive imaging methods used to diagnose stable CAD, coronary angiography (CAG) is still considered the “gold standard” in detecting obstructive coronary artery (CA) lesions. However, the invasive nature of CAG makes this procedure less desirable as a first-line study, especially considering that up to two thirds of patients with suspected stable angina do not have obstructive CAD according to CAG, even though previously non-invasive testing has been done. In addition, in real clinical practice, in a significant number of patients, invasive CAG is performed without sufficient evidence, as a result, it does not reveal a significant damage to CA. It turns out that diagnostic algorithms for examining patients with suspected CAD, presented in international and national guidelines, based on modern non-invasive diagnostic methods, do not affect the detection rate of CA obstructive lesions in CAG. At the moment, the search for the optimal algorithm is the subject of lively discussions. The proposed review examines the diagnostic approaches of the European and British guidelines, as well as discrepancies regarding the diagnostic capabilities of the proposed non-invasive tests. In addition, the prospective use of anatomical non-invasive tests is discussed, in particular, the assessment of fractional blood flow reserve for multispiral computed tomography (FFRCT). This review will contribute to a better understanding of diagnostic strategies with stable CAD, both in scientific research and in clinical practice.