Signs of turf war over cardiac CT appear at SCCT meeting

The truce over cardiac CT between cardiologists and radiologists showed signs of strain last week at the Society of Cardiovascular Computed Tomography meeting in Washington, DC, when several radiologists charged that the endorsement of clinical guidelines by the society favored cardiologists.

The tension is a sign of caution for CT vendors whose 16- and 64-slice scanners are particularly suited to coronary CT angiography. Most sales of these systems have been in radiological settings, where applications have followed traditional paths. Cardiac applications, however, particularly coronary CTA, have been explored usually by cardiologists and radiologists working together.

CT luminaries have expressed hope that these fledgling alliances are the start of a long-term partnership between the two specialties. There is concern, however, that they may instead be a cautious way for cardiologists to gain experience with cardiac CT as a prelude to setting up their own cardiac CT practices, after third-party payers and Medicare expand reimbursement for coronary CTA.

The history of imaging is replete with examples of this happening, as cardiologists have taken control of cardiac catheterization, echocardiography, and nuclear cardiology. Industry pundits expect cardiologists to adopt cardiac CT in the future. Radiologists worry that they will be cut out. Some have voiced concerns regarding software that selectively reconstructs, as interpretations based solely on these reconstructions would not take into account other pathologies that might appear in the surrounding tissue, particularly the lungs.

A battle between radiologists and cardiologists with allegations of improper diagnostic approaches could slow the adoption of cardiac CT and with it the sale of high-performance systems.

Signs that the situation could get ugly surfaced at the SCCT meeting, when radiologists denounced the society for approving a cardiac CT guideline developed by the American College of Cardiology and American Heart Association and ignoring one by the American College of Radiology.

"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.

Dr. Mathew Budoff, a cochair of the SCCT accreditation, certification, and guidelines committee who helped write the ACC guidelines, defended the action, stating his opinion that the ACC guideline was the better of the two. He noted that radiologists made up the original group writing the ACC/AHA guidelines, but said they pulled out of the project two months before publication. He then tried to assuage the radiologist's concerns, stating that the SCCT is not siding with the ACC or the ACR.

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

The discussion became more heated, however, as a second radiologist questioned 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.

The rift was all the more significant because the society, which was formed only last year, aims to represent radiologists and cardiologists equally. Two-thirds of its 2000-strong membership, however, is composed of cardiologists.

At issue is the differing level of competence defined by the two guidelines. The one developed by the ACR calls for the interpretation of 75 cardiac CTs. The one from ACC/AHA calls for twice that number, and 50 of those must be live. 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 are scheduled to be published in August.

As Budoff's opinion regarding the inferiority of the ACR's guidelines was debated, Budoff opined further that interpreting 75 cases is not enough to qualify a physician to start interpreting cardiac CTA exams.

An 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.

The discussion ended on a conciliatory note sounded by the SCCT's vice president, Dr. Daniel Berman, director of cardiovascular imaging at Cedars-Sinai Medical Center in Los Angeles.

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