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Introduction: Non-invasive assessment of coronary artery disease (CAD) in patients with hypertensive heart disease is still a major clinical challenge. The aim of this meta-analysis was to evaluate the diagnostic accuracy of different non-invasive techniques in detecting significant (> 50%) CAD in hypertensive patients.

Material and methods: We systematically searched selected electronic databases from inception until February 27(th) 2024. The main clinical endpoint was the diagnostic accuracy of non-invasive investigations including exercise electrocardiography test (EET), stress echocardiography (SE) and myocardial perfusion imaging (MPI). Random effects summary receiver operating characteristic analysis was performed.

Results: Twenty-five papers with a total of 3812 patients with systemic hypertension and suspected or known significant CAD were finally included in the meta-analysis. The diagnostic accuracy of SE was the highest compared to the two other investigations (85%, 72%, 53%, p < 0.05 for all). SE had higher sensitivity 85% (83-87%) and specificity 81% (79-83%) compared to MPI (sensitivity 81% (77-83%), specificity 64% (59-68%)) and EET (sensitivity: 53% (50-65%) and specificity 51% (47-54%)). All three tested investigations had higher accuracy in patients with multivessel disease compared to those with single-vessel disease (p < 0.05 for all). The diagnostic accuracy of SE and MPI was not significantly impacted by left ventricular hypertrophy (p > 0.05 for both) compared to EET, which was lower in patients with hypertrophy compared to those without (41% vs. 58%, p = 0.03). These results were consistent irrespective of the stress echo modality, physical, exercise or pharmacological (p > 0.05).

Conclusions: This meta-analysis reveals the powerful diagnostic value of stress echocardiography in detecting significant coronary artery disease in hypertension patients.