Use Coronary CTA First for Evaluating Patients with Stable Coronary Artery Disease

Using coronary CT angiography to evaluate patients who have stable chest pain can improve their outcomes, as well as lower their costs, a group of experts have said.

In the September issue of the Journal of the American College of Cardiology, experts from the American College of Cardiology (ACC) published recommendations that point to a need to shift away from other tests toward greater coronary CTA use.

This guidance, based on the expert consensus from the ACC Summit on Technology Advances in Coronary Computed Tomography Angiography, reflects evidence showing that for patients with no known coronary artery disease, detection of the condition should pivot from identifying myocardial perfusion abnormality to pinpointing coronary atherosclerosis through CTA-first. Europe has already changed their guidelines based on these recommendations and evidence.

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“In countries around the world, cardiac CT has been adopted as a first-line diagnostic test in patients with stable chest pain,” said Koen Nieman, M.D., Ph.D., Summit president, “and I have no doubt this strategy will be embraced in the U.S. as well if appropriate conditions can be established.”

Currently the U.S. ratio of SPECT myocardial perfusion imaging to coronary CTA testing is 58:1.

To move the industry toward coronary CTA-first, the ACC made these recommendations:

•  Use coronary CTA as a first-line test for evaluating patients with stable chest pain and low-to-intermediate pre-test probability of obstructive CAD
•  Explore options for “bundled payments” for cardiac testing
•  Identify expert and financial support to increase the number of capable coronary CTA providers
•  Develop strategies to improve provider and delivery team competency in performing coronary CTA
•  Establish an ACC coronary CTA registry for evaluating chest pain that will include medical and economic variables for evaluating the total cost of care associated with coronary CTA
•  Engage commercial payers in discussions on eliminating pre-approvals for coronary CTA and FFR CT for providers participating in the coronary CTA registry
•  Improve education of cardiologists and primary care physicians on when to consider coronary CTA testing versus other techniques

 The ACC did caution, however, that more wide-spread use of CTA does present challenges.

Although CT scanners are widely available, greater CTA implementation calls for more education and training of medical professionals (both radiologists and cardiologists) to ensure they capture images of high diagnostic quality. In addition, providers need higher reimbursement for the service, and improvements must be made with insurance pre-authorizations.