Both cardiac CT and MR imaging are poised for continued growth. Efforts to improve MR’s simplicity and reduce the radiation exposure associated with CT will keep drawing both cardiologists and radiologists into the fold.
“Cardiac CT is experiencing enormous clinical growth,” says James Min, MD, assistant professor of medicine in radiology at Weill Medical College of Cornell University and director of cardiac CT at New York Presbyterian Hospital in New York City. “As more data accrue on CT, people are starting to gradually more and more see the great clinical impact the test can have on patient care. The test will become even more popular. Even now, the images are just exquisite.”
Show them the money
One drawback to cardiac CT is reimbursement or the lack thereof. The Centers for Medicare & Medicaid Services has said that it might consider the technical component of the exam to be the median average of local Medicare. That would come to $312.
“If reimbursement is not in that ballpark, nobody is going to buy a scanner,” says Min. Reimbursement has proven to be “a moving target,” he says. Medicare assigned experimental billing codes to drive data collection based on utilization patterns. Other payors then said that since Medicare considers the procedure experimental, they won’t pay. A “final” national coverage determination expected next March will probably just keep the issue in limbo, Min says.
Meanwhile, research has shown that the test is highly accurate and can rule out obstructive coronary disease. “We’ve seen a high amount of clinical acceptance,” Min says. In fact, the Society of Cardiovascular CT, formed in 2005, already has more than 4,000 members from a pool of 30,000 to 40,000 cardiologists in the United States. “Clearly, people like this test and think it’s going to be useful in managing patients with cardiac conditions.”
Min uses 64-slice GE Healthcare LightSpeed VCT and VCT XT with SnapShot Pulse and the GE Healthcare Advantage Workstation. The XT version offers prospective axial gating. By only exposing the patient at brief points in the heart’s cycle, radiation dose is reduced by 80 to 85 percent. He plans on purchasing another 64-slice scanner, solely for cardiac imaging, for an outpatient imaging center.
“We anticipate growth. We’re of the mind that it’s better to establish practice patterns early and worry about the money later.”
It can be tricky deciding when to jump into a new modality. Currently, cardiac CT is not a big moneymaker at most facilities, says Arthur Stillman, MD, professor of radiology and director of cardiothoracic imaging at Emory University School of Medicine in Atlanta, Ga. Stillman installed a Somatom Definition 64-slice scanner from Siemens Medical Systems in January. Depending on their situation, clinicians may want to wait until reimbursement improves. However, there is an advantage to being the leader in the local market. “Once established, it’s a powerful position to be in.”
Min favors getting into cardiac CT early. The private facilities that have made it work financially first and foremost provide a good service, he says. “The technology is there. If you wait four years and somebody else has set up shop—referral patterns are hard to break.”
Despite his satisfaction with the scanner, “until third-party payors are on board with this, we’re not going to see a lot of rapid growth,” Stillman says. More research on outcomes should help push payors along, he says. The technology is good for two large groups of patients: acute and chronic. “Most people don’t see this as a screening test for the worried well,” he says. “It probably isn’t worth the cost or even the radiation risk. But for someone with chest pain, it really changes the dynamics.”
Managing chest pain
Stillman says there is a lot of interest right now in acute chest pain. Patients with no changes seen in an electrocardiogram and unchanged enzymes make the cause of their chest pain unclear. “Oftentimes, these patients are admitted, they have multiple tests and are ultimately sent home because they don’t have a cardiac cause for chest pain. It’s very costly to do all of that.” Coronary CT angiography’s high negative predictive value makes it safe to send these patients home and several studies have demonstrated that.
Those with chronic chest pain are a much larger group. Up to 85 percent of patients at the typical cardiac cath lab don’t have acute chest pain. The COURAGE study, published earlier this year in The New England