Importance  Coronary computed tomography angiography (CCTA) is a new approach for the diagnosis of anatomical coronary artery disease (CAD), but it is unclear how CCTA performs compared with the standard approach of functional stress testing.

Objective  To compare the clinical effectiveness of CCTA with that of functional stress testing for patients with suspected CAD.

Data Sources  A systematic literature search was conducted in PubMed and MEDLINE for English-language randomized clinical trials of CCTA published from January 1, 2000, to July 10, 2016.

Study Selection  Researchers selected randomized clinical trials that compared a primary strategy of CCTA with that of functional stress testing for patients with suspected CAD and reported data on patient clinical events and changes in therapy.

Data Extraction and Synthesis  Two reviewers independently extracted data from and assessed the quality of the trials. This analysis followed the PRISMA statement for reporting systematic reviews and meta-analyses and used the Cochrane Collaboration’s tool for assessing risk of bias in randomized trials. The Mantel-Haenszel method was used to conduct the primary analysis. Summary relative risks were calculated with a random-effects model.

Main Outcomes and Measures  The outcomes of interest were all-cause mortality, cardiac hospitalization, myocardial infarction, invasive coronary angiography, coronary revascularization, new CAD diagnoses, and change in prescription for aspirin and statins.

Results  Thirteen trials were included, with 10 315 patients in the CCTA arm and 9777 patients in the functional stress testing arm who were followed up for a mean duration of 18 months. There were no statistically significant differences between CCTA and functional stress testing in death (1.0% vs 1.1%; risk ratio [RR], 0.93; 95% CI, 0.71-1.21) or cardiac hospitalization (2.7% vs 2.7%; RR, 0.98; 95% CI, 0.79-1.21), but CCTA was associated with a reduction in the incidence of myocardial infarction (0.7% vs 1.1%; RR, 0.71; 95% CI, 0.53-0.96). Patients undergoing CCTA were significantly more likely to undergo invasive coronary angiography (11.7% vs 9.1%; RR, 1.33; 95% CI, 1.12-1.59) and revascularization (7.2% vs 4.5%; RR, 1.86; 95% CI, 1.43-2.43). They were also more likely to receive a diagnosis of new CAD and to have initiated aspirin or statin therapy.

Conclusions and Relevance  Compared with functional stress testing, CCTA is associated with a reduced incidence of myocardial infarction but an increased incidence of invasive coronary angiography, revascularization, CAD diagnoses, and new prescriptions for aspirin and statins. Despite these differences, CCTA is not associated with a reduction in mortality or cardiac hospitalizations.

重要性  冠状动脉计算机断层造影血管造影（CCTA）是诊断冠状动脉解剖疾病（CAD）的一种新方法，但是与标准功能性压力测试方法相比，尚不清楚CCTA的表现如何。

目的  比较CCTA与功能性压力测试在怀疑CAD患者中的临床疗效。

数据来源  在2000年1月1日至2016年7月10日期间发布的CCTA英文随机临床试验中，在PubMed和MEDLINE中进行了系统的文献检索。

研究选择  研究人员选择了随机临床试验，将CCTA的主要策略与功能性压力测试的策略进行了比较，以用于可疑CAD患者，并报告了有关患者临床事件和治疗变化的数据。

数据提取和综合  两名审稿人独立地从试验中提取数据并评估了试验的质量。该分析遵循PRISMA声明进行系统评价和荟萃分析，并使用Cochrane协作工具评估随机试验中的偏倚风险。使用Mantel-Haenszel方法进行初步分析。摘要的相对风险是通过随机效应模型计算的。

主要结果和措施  感兴趣的结果是全因死亡率，心脏住院，心肌梗塞，有创冠状动脉造影，冠脉血运重建，新的CAD诊断以及阿司匹林和他汀类药物的处方变更。

结果  包括13个试验，对CCTA组的10 315例患者和功能性压力测试组的9777例患者进行了随访，平均持续时间为18个月。CCTA和功能性压力测试在死亡（1.0％vs 1.1％;风险比[RR]，0.93; 95％CI，0.71-1.21）或心脏住院治疗（2.7％vs 2.7％; RR，0.98）之间没有统计学上的显着差异； 95％CI，0.79-1.21），但CCTA与心肌梗死发生率降低相关（0.7％vs 1.1％； RR，0.71； 95％CI，0.53-0.96）。接受CCTA的患者更有可能接受有创冠状动脉造影（11.7％vs 9.1％; RR，1.33; 95％CI，1.12-1.59）和血运重建（7.2％vs 4.5％; RR，1.86; 95％CI，1.43- 2.43）。他们也更有可能接受新的CAD诊断并开始使用阿司匹林或他汀类药物治疗。

结论和相关性  与功能性压力测试相比，CCTA与减少心肌梗死的发生率有关，但与侵入性冠状动脉造影，血运重建，CAD诊断以及阿司匹林和他汀类药物新处方的发生率增加有关。尽管存在这些差异，但CCTA并未降低死亡率或减少心脏住院治疗。