Diagnostic performance between computed tomography angiography and high-sensitivity troponin for acute coronary syndrome in the emergency department: a systematic review and meta-analysis

Introduction

Acute chest pain is a common reason for presentation to the emergency department (ED) (1). Given that most patients present with normal electrocardiograms and cardiac biomarkers at initial assessment, the accurate identification and evaluation of acute chest pain poses a significant challenge for emergency physicians (2-4). Due to insufficient evidence, a substantial proportion of acute coronary syndrome (ACS) patients are erroneously discharged from the ED. This results in a twofold increased risk of myocardial infarction (MI) and mortality compared to hospitalized patients, leading to poorer outcomes and being associated with a rising incidence of medical malpractice claims (5-9). On the other hand, a large number of patients presenting with acute chest pain undergo extensive clinical observations and tests due to excessive concern about excluding ACS, yet only a minority are ultimately diagnosed with ACS or MI. This leads to an excessive drain on healthcare resources. Therefore, rapid diagnosis of ACS in the ED is crucial for initiating effective evidence-based medical treatment and management, particularly among low- to moderate-risk acute chest pain patients. This approach will further reduce healthcare costs and enhance patient health benefits (10,11).

Computed tomography angiography (CTA) is a rapid, non-invasive diagnostic tool offering high diagnostic accuracy and positive predictive value in the identification and stratification of ACS (12,13). Due to the delayed rise in circulating cardiac troponin levels, this results in reduced sensitivity of standard cardiac troponin testing, particularly at the onset of symptoms in patients (11,14). Concurrently, CTA provides unique advantages by visualizing the location, degree of stenosis, and blood flow status of coronary atherosclerosis (15). Another diagnostic method for evaluating and diagnosing ACS, troponin testing, has gained recognition among ED physicians for its ability to predict near-term, mid-term, and even long-term outcomes in ACS patients (16). The use of high-sensitivity troponin (hsTn) testing further enhances the diagnostic efficacy of this assessment (17). Its high sensitivity and precision aid in the early identification and stratification of ACS, as well as the prompt exclusion of acute myocardial infarction (AMI).

Therefore, rapidly and accurately identifying ACS patients in the ED, particularly those with low to moderate risk acute chest pain, and making clinically logical decisions will maximize patient benefit. Selecting appropriate diagnostic tests with high accuracy is challenging. CTA and hsTn are currently the primary diagnostic tools for evaluating acute chest pain patients in the ED, complementing clinical assessment—especially when ECG and cardiac markers are negative. The purpose of this meta-analysis was to assess and compare the diagnostic utility of CTA and hsTn in identifying ACS patients presenting to the ED. We present this article in accordance with the PRISMA-DTA reporting checklist (18) (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1070/rc).

Methods

The study was registered in PROSPERO (ID: CRD420251232056).

Study selection

Two researchers independently retrieved all original literature concerning the diagnostic efficacy of CTA and/or hsTn for ACS in the ED from PubMed, Embase, and Cochrane Library. The search covered all articles published up to October 2025, employing search terms including “acute coronary syndrome”, “computed tomography angiography”, “high-sensitivity troponin”, and “emergency department”. Included studies were unrestricted by publication date or region but limited to English articles. The specific search strategy, exemplified by PubMed, is detailed in Appendix 1.

Inclusion and exclusion criteria

The inclusion criteria for this meta-analysis were: (I) use of CTA and/or hsTn examination in the ED; (II) ACS as the clinical outcome or endpoint; (III) subjects being initially assessed with negative electrocardiograms and biomarkers, excluding MI; (IV) adoption of the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for assessing ACS and defining major adverse cardiac events (19); (V) provision of a complete 2×2 diagnostic table [true positive (TP), false positive (FP), false negative (FN), true negative (TN)] or sufficient detail to derive these data.

Exclusion criteria: (I) duplicate publications, editorials, conference abstracts, review articles, etc.; (II) literature failing to meet the objectives of this study or lacking sufficient data; (III) literature insufficient for extracting a 2×2 diagnostic table.

Screening and data extraction

Two researchers independently screened all literature. After excluding duplicates, articles irrelevant to the study objectives were filtered based on titles and abstracts. Full texts were subsequently reviewed to ensure final inclusion met the meta-analysis criteria. Disputes were resolved through consensus or consultation with a third researcher.

Data were extracted from eligible studies according to the following requirements: (I) article characteristics, including first author, publication year, region, study design, type, and blinding; (II) patient characteristics, including case numbers, age, patient status, inclusion and exclusion criteria; (III) assessment metrics of meta-analysis, including positive definitions for CTA and hsTn, and criteria for ACS evaluation; (IV) performance indicators, including TP, FP, FN,TN, sensitivity, and specificity. Where original studies reported differing outcomes for the same cohort due to varying diagnostic criteria, all relevant data were incorporated into the analysis.

Quality assessment

The methodological quality of all eligible studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool (20). Where discrepancies arose, these were resolved through consultation. The quality assessment comprised four primary domains: patient selection, index test, reference standard, and flow and timing. Each domain contained distinct sub-questions requiring judgement to further evaluate risk of bias. The first three domains collectively formed the basis for the clinical applicability assessment.

Statistical analysis

By extracting and analyzing diagnostic data from original studies, appropriate models were employed to separately evaluate the diagnostic efficacy of CTA and hsTn for ACS. A meta-analysis yielded pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR), presented alongside a forest plot. Furthermore, the area under the curve (AUC) values of the summary receiver operating characteristic (SROC) curves were compared to assess their diagnostic value.

Heterogeneity assessment employed chi-squared tests and I² statistics; heterogeneity was deemed present when I²>50% and P<0.05, whereas I²<50% and P>0.05 indicated no or minimal heterogeneity. Spearman’s correlation coefficients for sensitivity and specificity across all included studies were calculated to evaluate diagnostic threshold effects on meta-analysis outcomes. Sources of heterogeneity were explored primarily through subgroup analysis, sensitivity analysis, and publication bias (Deek’s funnel plots), with publication bias discussions omitted for studies with insufficient sample sizes. Additionally, Fagan plots were employed to assess clinical utility, representing the posterior probability of ACS based on the prior probability or probability of suspected ACS.

The methodological quality assessment in this study was conducted using Review Manager (RevMan) 5.3, while data analysis and synthesis employed Stata 14. P<0.05 were considered statistically significant, with all results summarized using 95% confidence intervals (CIs).

Results

Selection results

An initial search of PubMed, Embase, and the Cochrane Library yielded 1,494 articles. After removing duplicate studies, 1,164 studies remained. Following the further exclusion of case reports, reviews and other studies that did not meet the inclusion criteria, 541 studies remained. Following assessment of titles and abstracts for meta-analysis eligibility, 93 articles were selected for full-text review. After full-text evaluation, 21 articles were ultimately included in the analysis (21-41). The detailed workflow is illustrated in Figure 1.

Figure 1 The flowchart of the included studies.

Basic characteristics of the included studies

Fourteen studies evaluated the diagnostic efficacy of CTA for ACS in the ED (21,22,25-29,33,35-38,40,41); the majority of patients presented with acute chest pain at low-to-intermediate risk. Among 2,383 patients, 665 were diagnosed with ACS while 1,718 were no ACS. Only one study was retrospective (35), while 13 were prospective (21,22,25-29,33,36-38,40,41). Two studies were multi-centre (22,41), while 12 were single-centre (21,25-29,33,35-38,40); 6 studies employed blinding (22,25,27-29,41), and 8 were non-blinding (21,26,33,35-38,40); Regarding the definition of positive CTA, 11 studies reported ≥50% stenosis (21,22,25,27-29,33,35-37,40), while 4 studies reported >70% stenosis (21,22,26,38); detailed descriptions are provided in Table 1 and Table S1.

Seven studies evaluated the diagnostic value of hsTn for ACS in the ED (23,24,30-32,34,39). The majority of patients included were those presenting with acute chest pain at low to intermediate risk, totalling 1,856 patients. Among these, 242 had ACS and 1,614 did not. 2 studies were retrospective (30,31), while 5 were prospective (23,24,32,34,39). Four studies were single-centre (30,32,34,39) and 3 were multi-centre (23,24,31). 4 studies employed non-blinding (30-32,34), while 3 used blinding (23,24,39). The majority defined abnormal level of hsTn at 13 pg/mL (the 99th percentile value) (30,32,39). Detailed descriptions are provided in Table 1 and Table S1.

Results of methodological quality assessment

Quality assessments were conducted for all eligible studies, with results presented in Figure 2. The QUADAS-2 assessment indicated that the overall quality of the studies was high, rendering the meta-analysis results reasonably reliable. The risk of bias plots also demonstrated good stability.

Figure 2 Methodological quality assessment of the included studies. (A) Each studies; (B) summary.

The diagnostic efficacy of CTA for ACS

A total of 14 studies evaluated the diagnostic value of CTA for ACS (21,22,25-29,33,35-38,40,41). The meta-analysis yielded pooled sensitivity, specificity, PLR, NLR, and DOR of 0.94 (95% CI: 0.89–0.97), 0.83 (95% CI: 0.73–0.90), 5.7 (95% CI: 3.5–9.4), 0.07 (95% CI: 0.04–0.13), and 81 (95% CI: 36–181), respectively, as detailed in Table 2. Figure 3A,3B and Figure S1A,S1B present the pooled results of the forest plot of the meta-analysis. The AUC value for the SROC curve was 0.96 (95% CI: 0.94–0.97), indicating excellent predictive performance of CTA for ACS in the ED. It enables the rapid identification of ACS in patients with acute chest pain, thereby facilitating the formulation of more precise treatment strategies and reducing the risk of missed or misdiagnosed cases. This meta-analysis employed a mixed-effects model, with an overall I²>50% (P<0.05), suggesting substantial heterogeneity among studies. Furthermore, the Fagan nomogram indicates a pre-test probability of 48%. Following meta-analysis, the post-test probability of PLR increased from 3% to 84%, while NLR decreased from 0.07% to 6%.

Figure 3 Forest plots of diagnostic accuracy of CTA and hsTn for ACS. (A,B) Pooled sensitivity and specificity of CTA; (C,D) pooled sensitivity and specificity of hsTn. ACS, acute coronary syndromes; CI, confidence interval; CTA, computed tomography angiography; hsTn, high-sensitivity troponin.

Subgroup analysis and sensitivity analysis based on CTA study

In assessing the diagnostic value of CTA for ACS, meta-analysis results demonstrated considerable heterogeneity. We therefore evaluate the sources of this heterogeneity by subgroup and sensitivity analysis. This meta-analysis grouped studies according to study type (retrospective/prospective), study design (single-centre/multi-centre), blinding (no/yes), and positive CTA definition (≥50%/>70% stenosis). Results indicated that study design, blinding, and positive CTA definition may be sources of heterogeneity (I²>50%, P<0.05). Within these subgroups, sensitivity was marginally higher in retrospective studies and the single-centre subgroup [0.97 (95% CI: 0.91–1.00) and 0.95 (95% CI: 0.91–0.99), respectively], while specificity showed more pronounced improvement in the non-blinding and >70% stenosis subgroups [0.93 (95% CI: 0.88–0.97) and 0.93 (95% CI: 0.86–1.00), respectively]. Details are presented in Table 3.

We assessed sources of heterogeneity by sequentially removing each study; I² did not show significant variation (Table S2), suggesting that heterogeneity may be present to some degree in each study.

The diagnostic efficacy of hsTn for ACS

Seven studies evaluated the diagnostic performance of hsTn for ACS in the ED (23,24,30-32,34,39). The meta-analysis yielded pooled sensitivity, specificity, PLR, NLR, and DOR of 0.84 (95% CI: 0.53–0.96), 0.76 (95% CI: 0.55–0.89), 3.4 (95% CI: 2.1–5.6), 0.21 (95% CI: 0.07–0.64), and 16 (95% CI: 7–38), respectively, as detailed in Table 2. Figure 3C,3D and Figure S1C,S1D present the pooled results of forest plot. The SROC curve for CTA in diagnosing ACS is shown in Figure 4A. The AUC value for hsTn in assessing ACS was 0.86 (95% CI: 0.82–0.88), as shown in Figure 4B. Although the diagnostic accuracy of hsTn is not as high as that of CTA, in clinical practice the two complement each other, further improving the detection of ACS and reducing the risk of adverse outcomes. Results were analyzed using a mixed-effects model, with I²>50% (P<0.05), indicating substantial heterogeneity in the meta-analysis. Fagan nomogram for the CTA diagnosis of ACS is shown in Figure S2A. As depicted in the Fagan nomogram, the pre-test probability for ACS prediction by hsTn was 45%. Post-test prediction showed PLR increased from 3% to 74%, whilst NLR decreased from 0.21% to 15%, as illustrated in Figure S2B.

Figure 4 SROC for CTA (A) and hsTn (B) in the diagnosis of ACS. ACS, acute coronary syndromes; AUC, area under the curve; CTA, computed tomography angiography; hsTn, high-sensitivity troponin; SENS, sensitivity; SPEC, specificity; SROC, summary receiver operating characteristic.

Subgroup analysis and sensitivity analysis based on hsTn study

Given the substantial heterogeneity observed in the meta-analysis results for hsTn prediction of ACS, further subgroup and sensitivity analysis were conducted to assess the sources of this heterogeneity. Subgroup analysis was not performed for the definition of abnormal hsTn values, as these varied across studies in terms of units, measurement techniques, and cut-off values. Subgroup analysis was conducted based on study type (retrospective/prospective), study design (single-centre/multi-centre), and blinding (no/yes). Results revealed significant heterogeneity solely in study design (I²>50%, P<0.05). Sensitivity notably improved in the multi-centre and blinding subgroups, reaching 0.93 (95% CI: 0.81–1.00) and 0.91 (95% CI: 0.79–1.00), respectively. Conversely, specificity showed greater enhancement in the single-centre and non-blinding subgroups, with 0.85 (95% CI: 0.75–0.94) and 0.85 (95% CI: 0.74–0.96). Detailed results are presented in Table 3.

By excluding each relevant study to assess heterogeneity, it was found that I² did not exhibit significant variation (Table S2), indicating that heterogeneity was present in every individual study.

Publication bias and threshold effect

Publication bias in studies was assessed by Deek’s funnel plots, revealing that publication bias may be a source of heterogeneity in studies evaluating CTA for ACS (P=0.01, Figure S3). In studies of hsTn for predicting ACS, no discussion of publication bias was conducted due to insufficient original literature.

In the meta-analysis results for CTA and hsTn in diagnosing ACS, Spearman’s correlation coefficients were −0.43 (P<0.01) and −0.20 (P<0.01), respectively, suggesting that threshold effects may also contribute to heterogeneity.

Comparative value of CTA and hsTn for diagnosis of ACS

Some meta-analysis results are summarized in Table 2. Our findings indicate that in the assessment of ACS in the ED, CTA demonstrated a significant advantage over hsTn, with an AUC value as high as 0.96 (95% CI: 0.94−0.97, P<0.05).

Discussion

This review and meta-analysis summarizes and compares the diagnostic performance of CTA and hsTn for ACS in the ED. Our meta-analysis results, based on 21 original studies, indicate that the AUC value for CTA in assessing ACS was 0.96 (95% CI: 0.94−0.97), whereas the AUC value for hsTn in 7 studies was 0.86 (95% CI: 0.82−0.88). CTA has higher diagnostic accuracy than hsTn, suggesting that CTA is more likely to effectively rule out ACS in patients at low to moderate risk. In clinical practice, the combined use of both tests can further improve accuracy, enabling clinicians to formulate appropriate treatment strategies. ACS constitutes a clinical syndrome arising from acute myocardial ischaemia (42), with approximately one quarter of patients progressing to ST-segment elevation MI (43). This significantly elevates mortality rates and adverse outcomes, rendering early, accurate identification and initiation of effective resuscitation critical (44). In the clinical assessment of patients presenting with acute chest pain, CTA has emerged as a valuable tool for excluding coronary artery disease (45-47). Furthermore, CTA is now recognized as a useful non-invasive alternative to invasive coronary angiography (ICA) (48). Studies have confirmed the diagnostic value of CTA in patients with non-ST-segment elevation-ACS and demonstrated that CTA can be safely employed as a substitute for ICA. Moreover, CTA can also evaluate other cardiac and non-cardiac issues, such as aortic dissection, providing emergency physicians with additional differential diagnostic information. This enables more comprehensive management of patients presenting with acute chest pain and contributes to reduced mortality rates. Recently, cardiac troponin has been recognized as the preferred biomarker for predicting MI, a position confirmed in recent consensus guidelines (30). As a novel cardiac marker, high-sensitivity cardiac troponin has demonstrated greater sensitivity and faster detection of myocardial injury (44). Consequently, hsTn is becoming increasingly important in the diagnostic pathway and risk stratification of acute chest pain patients in the ED. However, its application remains constrained by variations in detection technologies, definitions of diagnostic threshold, and algorithmic configurations. Nevertheless, as a highly sensitive, non-invasive diagnostic tool capable of rapidly identifying and stratifying acute chest pain patients, it undeniably holds the potential to substantially reduce healthcare costs.

This meta-analysis evaluated and compared the diagnostic efficacy of CTA and hsTn for ACS in the ED, primarily involving low-to-intermediate risk chest pain patients. In another meta-analysis by Samad et al., CTA demonstrated a sensitivity of 95% and specificity of 87% for diagnosing acute chest pain patients (49). This aligns with our findings, though our meta-analysis incorporated a larger number of original studies and a broader cohort of chest pain patients, yielding more robust results. In addition, our meta-analysis included an assessment of hsTn. Furthermore, a meta-analysis encompassing 56 studies and 67,945 patients demonstrated that hsTn exhibits high diagnostic performance for MI, with a sensitivity as high as 93% (50); Setting different thresholds (5 or 3 ng/L) further increases sensitivity, albeit at the expense of specificity. Kavsak et al. found that setting the cut-off at 14 ng/L yielded the highest accuracy for predicting high-risk cardiovascular disease using hsTn (51). This assertion was corroborated in the study by Zhelev et al. (52). The aforementioned research has predominantly focused on the predictive value of hsTn for AMI, likely owing to the fact that in high-risk chest pain patients, myocardial necrosis is more severe, leading to higher elevations in cardiac markers, thereby rendering its clinical utility more pronounced. Our study aimed to evaluate the diagnostic value of hsTn in ACS patients, particularly among those presenting as low-to-intermediate risk at initial consultation. Such patients may exhibit negative myocardial markers at first presentation, necessitating highly sensitive and accurate detection tools to identify them, thereby reducing misdiagnosis rates and mortality. Meta-analysis results indicate that hsTn demonstrates diagnostic sensitivity and specificity of 84% and 76% respectively for ACS patients. While its predictive accuracy falls short of that for MI, it plays a crucial predictive role in early risk stratification and treatment decision-making. Furthermore, the study results indicate that CTA demonstrates higher diagnostic performance than hsTn. This suggests that, when assessing patients with acute chest pain, CTA may be a more effective method for ruling out ACS and facilitating risk stratification; meanwhile, the AUC value of 0.84 for hsTn indicates that it can also serve as an adjunctive diagnostic tool for identifying ACS. However, whilst our findings yield positive conclusions and can provide some guidance to ED clinicians, the selection of appropriate diagnostic tools requires careful consideration within the complex clinical setting. For instance, CTA allows for a relatively intuitive assessment of the patient’s disease progression and complexity, clearly visualizing vascular status, whereas hsTn, being a rapid serological test, can provide valuable information and guidance in the early stages of the disease. Furthermore, the combined use of both approaches would further improve sensitivity and negative predictive value, whilst reducing patient distress and healthcare costs.

The results of the meta-analysis exhibited heterogeneity. In subgroup analysis, significant heterogeneity was observed across all subgroups except for study type. This may be attributable to multiple factors in the original studies, including inclusion criteria, patient status, underlying conditions (diabetes, hypertension, smoking), and ethnicity. Furthermore, the definition of positive CTA (≥50% or 70% stenosis) for assessing coronary artery stenosis was inconsistent across different studies. Furthermore, level of hsTn predominantly employed a fixed threshold (the 99th percentile) and were used in conjunction with clinical criteria over a 3-hour period [Global Registry of Acute Coronary Events (GRACE) score <140 and the requirement to be pain-free] (53). However, thresholds, timing algorithms, and detection techniques employed across different original studies were inconsistent, further contributing to the substantial heterogeneity observed in the results. This represents a limitation of our study.

This study also has some limitations. Firstly, the study results exhibit significant heterogeneity, which may affect the robustness and reliability of the meta-analysis. This is due to differences between the original studies, such as research methods, study populations, underlying conditions, and other factors; however, we have explored the sources of heterogeneity through subgroup analysis and sensitivity analysis. Due to the limited number of studies, this study does not discuss whether publication bias is one of the sources of heterogeneity. Secondly, a methodological limitation of this study lies in the indirect comparison. This is because the included studies reported diagnostic data for CTA and hsTn separately, rather than conducting head-to-head controlled trials. Consequently, it is not possible to completely rule out potential confounding factors across different studies, which may weaken the robustness of the findings. Furthermore, this study included different subgroups from the same study; this is because the original studies may have compared the diagnostic performance of different testing methods, whereas in our study, different cohorts were included in the meta-analysis to meet the study objectives. Although this further increased the sample size, it also affected the generalizability of the study and increased heterogeneity. In addition, potential validation bias was prevalent in the included studies, which also posed a certain risk. Finally, although CTA has demonstrated high diagnostic performance in patients with low- to moderate-risk chest pain, its clinical application remains limited by inherent drawbacks, including unavoidable radiation exposure, relatively high examination costs, and limited availability in primary care settings. Therefore, in actual clinical practice, the diagnostic value of CTA should not be indiscriminately extrapolated to all situations.

Conclusions

This meta-analysis suggests that CTA offers promising diagnostic value in the early identification of ACS in patients with low- to moderate-risk acute chest pain presenting to the ED. In this specific population, the overall diagnostic performance of CTA is superior to that of hsTn. However, given that the specificity of CTA is only moderate and that there is heterogeneity between studies, the results should be interpreted with caution. Furthermore, the combined use of CTA and hsTn helps to optimize diagnostic accuracy and may reduce the unnecessary consumption of medical resources, providing a practical reference for individualized assessment strategies for chest pain in the ED.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-DTA reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1070/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1070/prf

Funding: This work was supported by Lanzhou Science and Technology Bureau (No. 2024-9-180).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1070/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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