Background: Among patients presenting with atypical acute chest pain with 30 to 70 years of age, 30 to 72% of the may have coronary arteries disease, CAD. CAD is the fifth Brazilian public health assistance most frequent motive and causes 20% mortality. When clinical information is unable to discriminates the chest pain etiology, diagnostic strategies include a series of biochemical and imaging indicators. Invasive coronary arteriography (ICA), is the established CAD diagnostic gold-standard involving risk of vascular dissection, infection and stroke. Evolving 3D imaging technologies may change paradigms. Methods: Systematic review, meta-analysis, decision analysis, utilization review from January 2004 to August 2005 and analysis of impact for the Brazilian public health care system. Results: Literature search identified 32 clinical trials comparing ICA and Multi-Detector-Row Computed Tomography Coronary Angiographies (MDCT-CA) between 1995 and May 2006; including 2054 patients and studying 21656 coronary segments. Regarding the consensus cutoff and its segment prevalence studied, the 16 MDCT-CA allowed to observe 95% of the segments observed at the invasive coronary angiography, presented a 6,5% false positive and a 4% false negative rates, with 83% sensitivity and 95% specificity. It presented a 80% positive and 97% negative predictive values. In summary, the 16 MDCT-CA presents an weighted average 85% operation receiver trend (95% CI from 71 to 99%) of accurate detection of 50% stenosis in coronary arteries with 1.5 mm diameter or more. During the study, 647 MDCT-CA were realized at the InCor (44% women, 57±12 of age versus 55±16 aged 66% men). ICA were necessary for 22% and 15%, female and male patients, among whom, respectively, were required 20% and 35% therapeutic intervention or surgery. The a priori screen with MDCT-CA of patients (near 20% presented with atypical acute chest pain and moderate or low risk of stenosis) would modify up to 53% their referrals for ICA. Weighted averages estimated cost for invasive diagnostic procedure were $605.00 and $191.00 for the non-invasive MDCT-CA. Average reimbursement during the study period were $2 500.00 for angioplasties and $3 200.00 for surgical revascularizations. In 2005, the Brazilian Health Care System, Sistema Único de Saúde, SUS, has registered access to 93.000 ambulatory events of attention and 56.210 hospital admissions due to acute angina. The latter included 35.880 coronary angioplasties and 20.330 myocardial surgical revascularizations. There are, thus, yearly, 30 000 Brazilians who may have atypical anginas. Impact prospection based on meta-analysis and InCor probabilities would estimate the 30 000 conventional invasive angiographies strategy to cost over 46,5 million US dollars and treat 10 320 cases (including required angioplasties and surgeries) compared to US$ 47,2 million, resulting from 30 000 MDCT-CA and the 13 950 angiographies to complete diagnosis with the treatment for 12 000 patients. Conclusion: Based on the meta-analytic and empirical probabilities, the decision analysis estimates MDCT-CA screen dominance, may allow 10% program savings (US$ 500.00 per case treated), avoid 50% diagnostic ICAs related to atypical anginas with reduced risk of stenosis, leading to more therapeutic procedures and may open over 10% more access to the public health care system. Study continuation is warranted with the new 64 row MDCT installed at the Heart Institute/ University of São Paulo Medical School
