CT coronary angiography (CTCA) has become an increasingly valuable tool in the assessment of coronary artery disease, particularly in patients with low to intermediate pre-test probability.

It offers excellent anatomical detail and a high negative predictive value, making it a useful test to exclude significant coronary disease.

That said, one of the key challenges in day-to-day practice is ensuring CTCA is used in the right clinical context.

We are seeing a growing number of patients presenting with a strong expectation of undergoing CTCA, often driven by online information or anecdotal experiences. However, CTCA is not always the most appropriate first-line investigation, and in many cases a functional test such as a stress echocardiogram remains the better initial approach.

When is CTCA most useful?

CTCA is particularly helpful in:

• Patients with low to intermediate risk of coronary artery disease
• Assessment of atypical chest pain
• Patients with equivocal or inconclusive prior functional testing

When a Stress Echocardiogram may be more appropriate

A stress echocardiogram is often a more suitable first-line investigation in patients:

• With typical or exertional chest pain
• Where the question is ischaemia and functional significance, rather than anatomy
• With known risk factors where functional capacity and inducible ischaemia are key considerations
• Where avoiding unnecessary radiation exposure is preferable

Why specialist review still matters

In Australia, CTCA requires specialist referral, providing an important opportunity to ensure the most appropriate investigation is selected for each patient.

Our approach is always to:

• Assess the clinical presentation and risk profile
• Select the most appropriate first-line investigation
• Avoid unnecessary testing or duplication
• Provide a clear diagnostic pathway and management plan

While CTCA is an excellent test when used appropriately, starting with the wrong investigation can sometimes lead to additional testing, increased cost, and patient confusion.

Working with you

If you have a patient where CTCA may be appropriate, we’re very happy to review them promptly and arrange this where indicated.

Equally, if a stress echocardiogram or alternative investigation is more suitable, we will ensure this is organised without delay.

Our goal is to support timely, accurate diagnosis while ensuring patients receive the most appropriate care from the outset.

Limitation of CTCA

CTCA is purely an anatomical test and does not necessarily guarantee coronary intervention if patients do not have typical anginal symptoms or evidence of inducible ischaemia on functional testing. This can occasionally create confusion for patients, particularly as guidelines surrounding coronary intervention have not changed despite the increasing availability of CTCA.