Cardiac CT: Ready for prime time as first line for suspected MI?

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CHICAGO–Cardiac CT angiography (CCTA) has demonstrated the capability to provide clinical information to help better manage patients for cardiologists employing the technology. In a spirited protagonist vs. antagonist presentation at the American College of Cardiology (ACC) 2008 Scientific Sessions March 30, a pair of clinicians foresees a greater role for CT in cardiology’s future.

L. Samuel Wann, MD, a cardiologist with the Wisconsin Heart and Vascular Clinic in Milwaukee, presented a wealth of current data supporting his contention that CCTA adoption makes strong economic and patient management sense. Citing numerous journal studies from the past few years, Wann observed that CCTA has demonstrated a near 100 percent negative predictive value; allowing clinicians to have confidence in ruling out additional cardiac testing.

Economically, according to data presented by Wann, CCTA is reimbursed at a rate more than 75 percent less than invasive coronary angiography—making it a more attractive procedure from a private and government payor perspective. Medicare reimbursement rates for the 2008 calendar year are set at:

  • CCTA: $650
  • myocardial perfusion imaging: $1,096
  • invasive coronary angiography: $2,860

“We need to be cognizant that the sky is not the limit for paying for all these studies that we’re talking about,” Wann said.

He noted that CT technology and techniques have room for improvement in its positive predictive value capabilities, currently approaching 90 percent.

Gregory S. Thomas, MD, a cardiologist with Mission Internal Medical Group in Mission Viejo, Calif., delivered the antagonist argument to the widespread adoption of CCTA as a first-line diagnostic option.

Thomas, citing data from 1993 and 1995 studies (conducted prior to the development and deployment of current-generation CT technology and visualization software), stated that physiology data led to better patient outcomes than anatomy-based visualization.

Thomas acknowledged that CT has made great strides in cardiac imaging since the data he presented was collected. In addition, he noted that the modality shows tremendous potential for the future; however, he believes that current technology is simply not adequate for the needs of cardiology.

“We need to really get better with our spatial and temporal resolution,” Thomas said. “We need more detector rows without the need for more radiation. We need to be able to conduct single-heartbeat imaging—in effect, we need a revolutionary new design, and we need to continue to work with the developers to continue to improve CT substantially over what it is currently.”

Wann, presenting a 3D cardiac CT reconstruction clearly demonstrating aortic dissection, said there was no question in his mind about the current utilization of CCTA in his practice.

“I don’t need a randomized, multi-center, double-blind, control study to tell me that I’m going to stick the guy in the CT machine for about 30 seconds if I’m going to get this kind of information,” he stated.