Objective To evaluate differences in downstream testing, coronary revascularisation, and clinical outcomes following non-invasive diagnostic modalities used to detect coronary artery disease.
Design Systematic review and network meta-analysis.
Data sources Medline, Medline in process, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, SCOPUS, WHO International Clinical Trials Registry Platform, and Clinicaltrials.gov.
Eligibility criteria for selecting studies Diagnostic randomised controlled trials comparing non-invasive diagnostic modalities in patients presenting with symptoms suggestive of low risk acute coronary syndrome or stable coronary artery disease.
Data synthesis A random effects network meta-analysis synthesised available evidence from trials evaluating the effect of non-invasive diagnostic modalities on downstream testing and patient oriented outcomes in patients with suspected coronary artery disease. Modalities included exercise electrocardiograms, stress echocardiography, single photon emission computed tomography-myocardial perfusion imaging, real time myocardial contrast echocardiography, coronary computed tomographic angiography, and cardiovascular magnetic resonance. Unpublished outcome data were obtained from 11 trials.
Results 18 trials of patients with low risk acute coronary syndrome (n=11 329) and 12 trials of those with suspected stable coronary artery disease (n=22 062) were included. Among patients with low risk acute coronary syndrome, stress echocardiography, cardiovascular magnetic resonance, and exercise electrocardiograms resulted in fewer invasive referrals for coronary angiography than coronary computed tomographic angiography (odds ratio 0.28 (95% confidence interval 0.14 to 0.57), 0.32 (0.15 to 0.71), and 0.53 (0.28 to 1.00), respectively). There was no effect on the subsequent risk of myocardial infarction, but estimates were imprecise. Heterogeneity and inconsistency were low. In patients with suspected stable coronary artery disease, an initial diagnostic strategy of stress echocardiography or single photon emission computed tomography-myocardial perfusion imaging resulted in fewer downstream tests than coronary computed tomographic angiography (0.24 (0.08 to 0.74) and 0.57 (0.37 to 0.87), respectively). However, exercise electrocardiograms yielded the highest downstream testing rate. Estimates for death and myocardial infarction were imprecise without clear discrimination between strategies.
Conclusions For patients with low risk acute coronary syndrome, an initial diagnostic strategy of stress echocardiography or cardiovascular magnetic resonance is associated with fewer referrals for invasive coronary angiography and revascularisation procedures than non-invasive anatomical testing, without apparent impact on the future risk of myocardial infarction. For suspected stable coronary artery disease, there was no clear discrimination between diagnostic strategies regarding the subsequent need for invasive coronary angiography, and differences in the risk of myocardial infarction cannot be ruled out.
Systematic review registration PROSPERO registry no CRD42016049442.

中文翻译：

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用于检测冠状动脉疾病的非侵入性诊断方式的结果：诊断性随机对照试验的网络荟萃分析

目的评估用于检测冠状动脉疾病的非侵入性诊断方式在下游检测、冠状动脉血运重建和临床结果方面的差异。
设计系统评价和网络荟萃分析。
数据来源Medline、Medline in process、Embase、Cochrane 临床试验图书馆、PubMed、Web of Science、SCOPUS、WHO 国际临床试验注册平台和 Clinicaltrials.gov。
选择研究的资格标准诊断性随机对照试验，比较出现低风险急性冠状动脉综合征或稳定性冠状动脉疾病症状的患者的非侵入性诊断方式。
数据综合随机效应网络荟萃分析综合了评估非侵入性诊断方式对疑似冠状动脉疾病患者下游检测和患者导向结果影响的试验的可用证据。方法包括运动心电图、负荷超声心动图、单光子发射计算机断层扫描-心肌灌注成像、实时心肌造影超声心动图、冠状动脉计算机断层扫描血管造影和心血管磁共振。未发表的结果数据来自 11 项试验。
结果纳入了 18 项针对低危急性冠状动脉综合征患者（n=11 329）的试验和 12 项针对疑似稳定型冠状动脉疾病患者（n=22 062）的试验。在低危急性冠状动脉综合征患者中，负荷超声心动图、心血管磁共振和运动心电图导致冠状动脉造影的侵入性转诊少于冠状动脉 CT 血管造影（优势比 0.28（95% 置信区间 0.14 至 0.57）、0.32（0.15 至0.71）和 0.53（0.28 到 1.00），分别）。对随后的心肌梗死风险没有影响，但估计值不准确。异质性和不一致性很低。在疑似稳定型冠状动脉疾病的患者中，负荷超声心动图或单光子发射计算机断层扫描-心肌灌注成像的初始诊断策略导致下游测试少于冠状动脉计算机断层扫描血管造影（分别为 0.24（0.08 至 0.74）和 0.57（0.37 至 0.87））。然而，运动心电图的下游检测率最高。在没有明确区分策略的情况下，对死亡和心肌梗塞的估计是不准确的。
结论对于低危急性冠状动脉综合征患者，负荷超声心动图或心血管磁共振的初步诊断策略与非侵入性解剖检查相比，较少转诊进行侵入性冠状动脉造影和血运重建手术，对未来心肌梗死风险没有明显影响. 对于疑似稳定型冠状动脉疾病，关于随后是否需要进行侵入性冠状动脉造影的诊断策略之间没有明确的区别，也不能排除心肌梗死风险的差异。
系统评价注册PROSPERO 注册号 CRD42016049442。