Non-invasive screening for coronary artery disease: current perspectives, patient, public health and ethical considerations in evaluating symptomatic and asymptomatic individuals

Coronary artery disease (CAD) is a leading cause of morbidity worldwide. Although non-invasive testing for CAD aims at reducing future disease burden, testing can often be associated with significant economic and other health-related costs, at both an individual and societal level. Although there is an established role for screening symptomatic patients for CAD, there is still considerable debate as to the best approach for individuals who are asymptomatic. In this review, various non-invasive tests commonly used in clinical practice will be discussed, including their potential utility, known limitations, and other considerations regarding their use. The use of such testing requires careful consideration of their diagnostic accuracy, availability, cost and patient-specific factors that may limit their utility and safety. Future recommendations for CAD screening, especially for lower-risk or asymptomatic individuals, should offer clinicians and patients some degree of flexibility and take into account the nuanced clinical approach that is often required to address the variability of each individual patient's biopsychosocial context and other factors relating to the suitability and accessibility of screening (e.g. financial cost and geographic location). Recommendations that are well suited to certain geographic locations or societal groups may be less appropriate for other populations, especially those that are marginalised, less well resourced or experiencing significant socioeconomic disadvantage. Screening for CAD should therefore endeavour to ensure equity and aim to improve outcomes in all patient groups, including those who are disadvantaged and most at risk.