ACR versus ACC guidelines debate jolts cardiovascular CT meeting

A few radiologists angrily denounced the Society of Cardiovascular Computed Tomography as favoring cardiologists over radiologists because it endorsed an accreditation document from the American College of Cardiology over one from the American College of Radiology.

The outburst, which took place at the inaugural meeting last week of the SCCT in Washington, DC, prompted the society's board to revisit and fine-tune its approach, Dr. John Lesser, cochair of the SCCT accreditation, certification, and guidelines committee, told Diagnostic Imaging after the meeting.

The SCCT, formed last year, has more than 2000 members, two-thirds of them cardiologists. The meeting's 800-plus attendees reflected the same ratio. The society aims to represent radiologists and cardiologists equally.

But when Dr. Mathew Budoff, the other cochair of the SCCT accreditation, certification, and guidelines committee, detailed the current state of accreditation for cardiac CT, he was accused of favoring the ACC over the ACR.

For political reasons, two competing guidelines exist for cardiac CT. (They also include cardiac MR.) One is an interim clinical statement from the ACR directed exclusively to radiologists and technologists. The other, jointly written by the ACC, American Heart Association, and a few other organizations, is a three-tiered model with different competencies geared to different needs:

• level I: understand cardiac CT

• level II: perform and interpret images

• level III: manage a CT laboratory

The ACR document focuses on practice competence, the issue equivalent to ACC level II. It requires the interpretation of 75 cardiac CT cases, excluding those performed for calcium studies only.

"There is no doing procedures, no doing live case visualization. You are just interpreting the cases. That's probably fairly easy," said Budoff, director of cardiac CT at the University of California, Los Angeles.

The ACC guidelines, however, require the interpretation of 150 studies, 50 of which must be live, to reach level II. Based on the ACC guidelines, the SCCT defined nuances such as the meaning of "case" and "live." The society's members approved the guidelines, which will be published in August, during an early Saturday business meeting.

When Budoff invited comments from the floor, a few radiologists expressed their displeasure.

"It seems to me that the SCCT has blessed the ACC guidelines. Clearly, as a radiologist who's actively involved in a cardiac CT program, it puts me in a bind as to which credential to pursue," said Dr. Jong Kim, a radiologist with Advanced Diagnostic Radiology in Cumberland, MD.

Budoff replied that he is biased because he helped write the ACC guidelines and thinks they are better. But he stressed that the opinion is personal and not the position of the SCCT. Radiologists made up the original group writing the ACC/AHA guidelines, but they pulled out of the project two months before publication.

"We're not siding with the ACC or the ACR," Budoff said. "We're not trying to pit radiologists against cardiologists. I understand that radiologists get stuck a bit in the middle, and we're very sensitive to that."

Another radiologist then took the mic and asked why, if the society is not siding with either organization, it endorsed the ACC document and not the ACR's?

"Because it's a fantastic document," said moderator Dr. L. Samuel Wann, a clinical professor of medicine at the University of Wisconsin, Madison and an SCCT board member.

Budoff explained that the ACR never asked the SCCT to participate. The organization could not, therefore, endorse guidelines it had no hand in developing.

The unidentified radiologist countered that Budoff gave his opinion that the ACR document is inferior to the ACC's. Budoff reiterated that it is his personal opinion that interpreting 75 cases is not enough to qualify someone to go out and start doing cardiac CTA exams.

The attendee then said that radiologists may look at it differently because they have already interpreted many CTs.

"We may feel you need to interpret thousands of CTs and go through four, five, six years of training before you can interpret cardiac CTA," he said.

Dr. Nathaniel Reichek, a professor of medicine at Stony Brook University of New York, approached the mic and said that the ACR had rejected an invitation from the Society of Cardiovascular Magnetic Resonance to join in the drafting of guidelines for cardiovascular MR.

"The general approach the ACR has taken has been to try to minimize the number of these subspecialty recommendations for competence of any kind. They've taken the broad view most often, that if you have done a radiology residency, clearly you are competent to do anything," Reichek said.

The last word was a conciliatory one from the SCCT's vice president, Dr. Daniel Berman, director of cardiovascular imaging at Cedars-Sinai Medical Center in Los Angeles.

"With an audience this size, it's very important for us to get the message across that SCCT is nonpartisan. We are all striving to get the best quality in the field of cardiac CT. I'm sure that everyone involved in the leadership of SCCT agrees," Berman said.

For more information from the Diagnostic Imaging archives:

Cardiac CT sets high bar for physician education

ACC: Cards must drive better imaging quality

Fusion poses training challenge for specialists

Congress grills officials about imaging benefits, costs