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Cardiac Imaging and Diagnostics / Cardiac Valve Diseases and Treatments · Review
Journal of Clinical Medicine · July 21, 2026
A consensus or society position rather than new primary data.
This narrative review establishes that the displacement of invasive coronary angiography by non-invasive modalities (CCTA, CT-FFR, PCCT, CMR) has occurred asymmetrically across clinical domains rather than uniformly. Non-invasive imaging is now first-line for stable chest pain at low-to-moderate pretest probability, pre-TAVR planning, and aortic disease; invasive angiography remains first-line for STEMI, cardiogenic shock, and complex PCI; and the boundary remains contested for stable multivessel disease and pre-CABG planning.
Narrative review. Published evidence and guidelines on coronary, valvular, and structural heart disease imaging across multiple clinical domains.
Non-invasive imaging established as first-line for stable chest pain at low-to-moderate pretest probability Non-invasive imaging established as first-line for pre-TAVR and structural procedural planning Non-invasive imaging established as first-line for aortic disease
Does not report effect sizes, outcome comparisons, or safety profiles for imaging modalities
Clinicians and heart teams should tailor the choice of first-line imaging (invasive vs. non-invasive) to disease domain, pretest probability, anatomical complexity, and whether diagnosis and treatment can be separated, recognizing that modalities are complementary rather than competing. Non-invasive imaging should be preferred in stable, low-complexity scenarios; invasive angiography remains essential when diagnosis and intervention are simultaneous.
A narrative review synthesizing randomized trials, registries, and society guidelines to establish domain-specific recommendations for the boundary between invasive and non-invasive cardiac imaging across multiple clinical scenarios.
As stated by the source record.
Clinicians and heart teams should tailor the choice of first-line imaging (invasive vs. non-invasive) to disease domain, pretest probability, anatomical complexity, and whether diagnosis and treatment can be separated, recognizing that modalities are complementary rather than competing. Non-invasive imaging should be preferred in stable, low-complexity scenarios; invasive angiography remains essential when diagnosis and intervention are simultaneous.
Graded across the dimensions that decide whether you should act, each from what the source actually supports. There is no single score, and where a dimension was not assessed it says so.
What is missing. This record has no reported figures. That is a gap in the analysis, not a judgement about the study.
Background: Invasive coronary angiography has historically been the reference standard for coronary, valvular, and structural heart disease. Over the past decade, coronary computed tomography angiography (CCTA), CT-derived fractional flow reserve (CT-FFR), photon-counting detector computed tomography (PCCT), and cardiac magnetic resonance (CMR) have expanded the range of clinical questions answerable without an intra-arterial catheter, but this shift has been uneven across clinical domains. Methods: We performed a narrative review and synthesis of randomized trials, registries, society guidelines, and consensus documents (2009–2026) identified through PubMed and major cardiovascular guideline databases, written from a joint cardiology and cardiac-surgical standpoint. Results: The boundary has shifted asymmetrically, by which we mean a domain-dependent rather than uniform displacement of invasive angiography. Non-invasive imaging is now established as the first-line approach for stable chest pain at low-to-moderate pretest probability, for pre-transcatheter aortic valve replacement (TAVR) and structural procedural planning, and for aortic disease. It remains contested for stable multivessel disease and pre-coronary artery bypass grafting (CABG) planning, where CCTA- or CT-FFR-only planning is still investigational. Invasive angiography stays first-line for ST-elevation myocardial infarction (STEMI), cardiogenic shock, and complex percutaneous coronary intervention (PCI), where diagnosis and therapy are inseparable. Conclusions: Invasive and non-invasive modalities are complementary rather than competing. The appropriate first-line investigation depends on the disease domain, pretest probability, anatomical complexity, imaging quality, and whether diagnosis and treatment can be separated. We propose a complexity-stratified, heart-team framework and identify the surgical research gaps that remain.
Taken from the source record, never inferred. Follow any of these and new work involving them reaches your briefing.