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100 80 60 40 20 0 0 20 40 60 80 100 Pre-test likelihood (%) Post-test likelihood (%) DSE + CCTA + CCTA - DSE - A B C Figure 8 Ruling in and ruling out functionally significant obstructive coronary artery disease by sequential anatomical (coronary computed tomography angiography) and functional (dobutamine stress echocardiography) testing.a CAD, coronary artery disease; CCTA, coronary computed tomography angiography; DSE; dobutamine stress echocardiography; ECG, electrocardiogram; FFR, fractional flow reserve. The curves display the post-test likelihood of obstructive CAD for a positive (+) and a negative (−) test result for CCTA and DSE, as the pre-test likelihood of obstructive CAD increases. The post-test likelihoods were calculated using the likelihood ratios taken from recent meta-analyses.148,388 aBased on invasive FFR measurement or diameter stenosis of ≥70%. • A 70-year-old woman with four coronary risk factors and exertional dyspnoea has a pre-test likelihood of 16% (A). A normal CCTA almost completely rules out obstructive CAD with a very low negative post-test likelihood (2%). • A 55-year-old man with two coronary risk factors and all three anginal symptom characteristics has a pre-test likelihood of 27% (B). An abnormal CCTA brings the post-test likelihood to 40%, insufficient to rule in obstructive CAD. Sequential testing with DSE performed after CCTA brings the post-test likelihood to 82%. A normal CCTA effectively rules out obstructive CAD. • A 69-year-old man with four coronary risk factors and all three anginal symptom characteristics has an adjusted pre-test likelihood of 60% (C) (adjustment based on abnormalities on the resting ECG and on symptoms during exercise). A positive DSE alone has a high post-test likelihood (± 90%). A negative DSE is associated with a 32% post-test likelihood. Sequential testing by CCTA would allow ruling out obstructive CAD (<5% post-test likelihood). Downloaded from academic.oup.com/eurheartj/article/45/36/3415/7743115 by guest on 07 October 2026