Coronary CTA Should Be First When Assessing Stable CAD: Consensus Document

A multidisciplinary consortium is recommending that coronary computed tomography angiography (CTA) be used as a first-line test to assess patients with stable CAD and called for the US guidelines to be updated accordingly.

With mounting evidence in favor of anatomic testing from PROMISE, SCOT-HEART, and most recently the ISCHEMIA trial, writing committee chair Michael Poon, MD (Lenox Hill Hospital-Northwell Health, New York, NY), told TCTMD that a tipping point has been reached. “We want to do the right thing, and the right thing is to do the test that shows us the most benefit for the management of our patients,” he said. “We're looking forward to this very exciting national movement with this position paper. It took 1 year in the making, but actually the effort started almost 20 years ago when I started cardiac CT.”

The document, published in the September 15, 2020, issue of the Journal of the American College of Cardiology, resulted from an American College of Cardiology (ACC)-sponsored roundtable meeting of imagers, invasive cardiologists, radiologists, and payers in September 2019.

Despite the available data regarding the benefits and potential cost savings of CTA over functional testing in patients without known CAD, 58 single-photon emission CT (SPECT) myocardial perfusion imaging studies are done in the United States for every single CTA, according to evidence cited by the writing committee. They attribute this discrepancy to a wider availability of nuclear medicine cameras and stress echocardiography labs, greater emphasis of functional over anatomical testing in fellowship programs, higher technical expertise needed to perform CTA, and variations in reimbursement that favor functional imaging.

“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 US, as well, if appropriate conditions can be established,” Koen Nieman, MD, PhD (Stanford University Medical Center, Palo Alto, CA), Society of Cardiovascular Computed Tomography president and writing committee member, said in a press release.

Both the UK and European society guidelines for “chronic coronary syndromes” have been updated to recommend coronary CTA as the preferred initial test for these patients. “It is time for the United States to do so,” Poon and colleagues write.

Nine Recommendations

In the paper, they make nine specific recommendations for how the healthcare community can move forward with a CTA-first model.

It starts with simply using and promoting CTA, Poon emphasized. “Obviously, we have to recognize the data is correct that we should use CTA as the default test,” he said.

Next, to tackle some of the financial disincentives currently working against CTA, the writing committee recommends both increasing payment for cardiac CT services and testing value-based “bundled payments.” Reimbursement for CTA has taken a hit in recent years, which Poon attributes to poor cost accounting given that coronary CT requires more effort and resources than other CT services.

Recommendations four and five have to do with increasing both the number and expertise of trained CTA providers. “We need to identify the experts in the field and help them to continue to grow their training programs and teach more doctors, fellows, nurses, and CT technologists to learn how to provide this service,” Poon said.

The consensus document also recommends the creation of a CTA registry to aid in assessing the total cost of this kind of imaging. “Ideally, commercial payers will collaborate with the ACC on this registry to validate costs,” they write.

It will also be important for both public and private payers to be involved in the ongoing advocacy work done by societies on behalf of cardiac CT. The writing committee calls for discussions with both the Centers for Medicare & Medicaid Services and US Congress as well as with commercial payers “to establish more equitable payment for CTA procedures.” They also seek to eliminate preapprovals for coronary CTA and CT-derived fractional flow reserve, “at least for providers participating in the aforementioned registry.”

Lastly, they endorse increased education among cardiologists and primary care physicians alike as to when and how they should refer patients for CTA and how to incorporate test results into their management plans.

Without taking these actions, Poon warned, “we will keep doing the wrong thing and costing the health system more and more and not saving more lives. We are one of the most expensive countries in the world at taking care of patients. That doesn't mean we have the best outcomes, and we need to change that.”