ABSTRACT
Introduction: Ischemic heart disease remains a leading cause of morbidity and mortality worldwide. Coronary computed tomography angiography (CCTA) is recommended by current European guidelines as a first-line test for suspected obstructive coronary artery disease, but data on its economic impact in Romania remain limited. We evaluated a CCTA-first diagnostic strategy compared with a hypothetical strategy of invasive coronary angiography (ICA) in all patients with intermediate pretest probability. Material and methods: We conducted a retrospective cohort study of 248 patients with intermediate pretest probability (15–50%; RF-CL model) who underwent CCTA as a first-line test. CCTA findings were classified according to CAD-RADS 2.0, and patients with obstructive stenoses or non-diagnostic examinations were referred for ICA. Diagnostic performance, ICA avoidance, and costs were evaluated and compared with a hypothetical ICA-for-all strategy. Results: The mean age was 58.5 ± 9.1 years, 41.9% of patients were women, and the mean pretest probability was 31.0 ± 9.8%. Confirmed obstructive coronary artery disease was present in 63 patients (25.4%). CCTA had a sensitivity of 95.2%, specificity of 82.7%, negative predictive value of 98.1%, and overall accuracy of 85.9%. The CCTA-first strategy avoided ICA in 151 patients (60.9%) and reduced the average cost per patient from 4,249 to 2,525 RON, representing a 40.6% reduction and total savings of 427,600 RON. The cost per correct diagnosis was 2,940 RON with the CCTA-first strategy. Conclusions: In patients with intermediate pretest probability, a CCTA-first diagnostic strategy substantially reduced costs and the need for invasive testing while providing high sensitivity and negative predictive value. These findings support the use of CCTA as a diagnostic gatekeeper in cardiology practice in Romania.