ACC led summit recommends Coronary CTA as a first-line test for the evaluation of patients with stable coronary artery disease

Arlington, VA (September 8, 2020) — The Journal of the American College of Cardiology (JACC) has published a September 2020 report, “Current Evidence and Recommendations for Coronary CTA First in Evaluation of Stable Coronary Artery Disease” that outlines the benefits of a coronary computed tomography angiography (CTA)–first strategy, as well as challenges and barriers related to this approach.

The report reflects expert consensus of attendees at the American College of Cardiology Summit on Technology Advances in Coronary Computed Tomography Angiography, held on September 18, 2019. It notes that despite evidence that a coronary CTA-first strategy can improve outcomes and may lower cost for patients with stable chest pain, the U.S ratio of nuclear single-photon emission CT (SPECT) myocardial perfusion imaging to coronary CTA testing is 58:1.

The statement outlines data that for patients who do not have known coronary artery disease (CAD), the detection of CAD should change from detection of a myocardial perfusion abnormality to detection of coronary atherosclerosis through a CTA-first strategy. The United Kingdom and the rest of Europe have changed their guidelines as a result of this evidence.

“The available evidence suggests that a coronary CTA-first strategy can provide important benefits to our patients, yet there are barriers to wider implementation, including inadequate payment, insufficient number of imagers (both cardiologists and radiologists) trained to interpret these tests, and a need for more education of referring physicians on when and how to utilize coronary CTA in patient care,” says SCCT Immediate Past President, Ron Blankstein, MD, MSCCT, who was part of the planning committee for the ACC summit.

Per the report, shifting from other forms of imaging to coronary CTA is not without its challenges. While CT scanners are widely available, more education and training of medical professionals is needed to produce high quality imaging, in addition to higher reimbursement and improved insurance pre-authorization.

SCCT President Koen Nieman, MD, PhD, MSCCT stated: “In countries around the world, cardiac CT has been adopted as a first-line diagnostic test in patients with stable chest pain, and I have no doubt this strategy will be embraced in the U.S. as well if appropriate conditions can be established.”

To move toward a coronary CTA-first paradigm, the ACC Summit attendees recommend the following:

  • 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.
  • Increase payment for coronary CTA and improve advocacy for coronary CTA by direct engagement with public and private payers.
  • 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. This registry could include medical and economic variables to evaluate “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 vs. other techniques.

The report provides evidence from the U.K. SCOTHEART (Scottish Computed Tomography of the Heart) trial, the U.S. PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial and early reports from the clinical trial ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches).