Advertisement

Barriers to Greater Clinical Implementation

  • David C. LevinEmail author
Chapter
Part of the Contemporary Medical Imaging book series (CMI)

Abstract

The cardiac imaging community is facing a peculiar paradox. There is abundant evidence showing that CCTA is the most appropriate initial imaging test in patients with suspected CAD. The evidence has been presented at length here and elsewhere in this textbook. Yet CCTA is far less commonly utilized than older, less effective tests like MPI and SE (recall that in the Medicare population, MPI is used 53 times as often as CCTA). Possible reasons for this have been discussed earlier. Hopefully some of the obstacles preventing greater use of CCTA will be resolved as time goes on. The imaging equipment will undoubtedly become faster, more efficient, and more automated, thus allowing radiologic technologists to do most of the work without requiring the presence of a physician. Advances in software and machine learning are already occurring and will allow for computer-aided identification of exams that are normal. We must do a better job at educating our primary care colleagues and the nurse practitioners and physician assistants who work for them about the advantages accruing to early use of CCTA in their chest pain patients. Cardiologists and other cardiac imagers who have become overly accustomed to using MPI (perhaps because they own the equipment) should be encouraged to change their approach. As Arbab-Zadeh has pointed out (Arbab-Zadeh A, J Am Coll Cardiol Img 9:565–567, 2016), CCTA has come a long way and is ready for prime time. Cardiologists and radiologists must work together to make it happen.

Keywords

Coronary artery disease Coronary CT angiography Radionuclide myocardial perfusion imaging Stress echocardiography Heart disease imaging 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Go AS, Mozaffarian D, Roger VL, et al. Executive summary: heart disease and stroke statistics – 2014 update. A report from the American Heart Association. Circulation. 2014;129:399–410.CrossRefGoogle Scholar
  2. 2.
    Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease. J Am Coll Cardiol. 2008;52:1724–32.CrossRefGoogle Scholar
  3. 3.
    Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008;359:2324–36.CrossRefGoogle Scholar
  4. 4.
    MeijboomWB MMFL, Schuijf JD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography. J Am Coll Cardiol. 2008;52:2135–44.CrossRefGoogle Scholar
  5. 5.
    Patel MR, Peterson ED, Dai D, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med. 2010;362:886–95.CrossRefGoogle Scholar
  6. 6.
    Schuijf JD, Wijns W, Jukema JW, et al. Relationship between noninvasive coronary angiography with multi-slice computed tomography and myocardial perfusion imaging. J Am Coll Cardiol. 2006;48:2508–14.CrossRefGoogle Scholar
  7. 7.
    Weustink AC, Moller NR, Neefjes LA, et al. Diagnostic accuracy and clinical utility of noninvasive testing for coronary artery disease. Ann Intern Med. 2010;152:630–9.CrossRefGoogle Scholar
  8. 8.
    Mark DB, Berman DS, Budoff MJ, et al. ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT expert consensus document on coronary computed tomographic angiography. Circulation. 2010;121:2509–43.CrossRefGoogle Scholar
  9. 9.
    Dorbala S, Hachamovitch R, Carli MF, et al. Myocardial perfusion imaging and multidetector computed tomographic coronary angiography. J Am Coll Cardiol. 2006;48:2515–7.CrossRefGoogle Scholar
  10. 10.
    Marwick TH, Cho I, Hartaigh B, Min JK. Finding the gatekeeper to the cardiac catheterization laboratory: coronary CT angiography or stress testing? J Am Coll Cardiol. 2015;65:2747–56.CrossRefGoogle Scholar
  11. 11.
    Dilsizian V, Taillefer R. Journey in evolution of nuclear cardiology. Will there be another quantum leap with the F-18 labeled myocardial perfusion tracers? J Am Coll Cardiol Cardiovasc Imaging. 2012;5:1269–84.CrossRefGoogle Scholar
  12. 12.
    Chinnaiyan KM, Raff GL, Goraya T, et al. Coronary computed tomography angiography after stress testing. Results from a multicenter statewide registry, ACIC (Advanced Cardiovascular Imaging Consortium). J Am Coll Cardiol. 2012;59:688–95.CrossRefGoogle Scholar
  13. 13.
    Arbab-Zadeh A, Di Carli MF, Cerci R, et al. Accuracy of computed tomographic angiography and single-photon emission computed tomography-acquired myocardial perfusion imaging for the diagnosis of coronary artery disease. Circ Cardiovasc Imaging. 2015;8:e003533.PubMedGoogle Scholar
  14. 14.
    Moscariello A, Vliegenthart R, Schoepf UJ, et al. Coronary CT angiography versus conventional cardiac angiography for therapeutic decision making in patients with high likelihood of coronary artery disease. Radiology. 2012;265:385–92.CrossRefGoogle Scholar
  15. 15.
    Lin FY, Shaw LJ, Dunning AM, et al. Mortality risk in symptomatic patients with nonobstructive coronary artery disease. J Am Coll Cardiol. 2011;58:510–9.CrossRefGoogle Scholar
  16. 16.
    Chow BJW, Wells GA, Chen L, et al. Prognostic value of 64-slice cardiac computed tomography. J Am Coll Cardiol. 2010;55:1017–102817.CrossRefGoogle Scholar
  17. 17.
    Min JK, Dunning A, Lin FY, et al. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings. J Am Coll Cardiol. 2011;58:849–60.CrossRefGoogle Scholar
  18. 18.
    Russo V, Zavalloni A, Reggiani MLB, et al. Incremental prognostic value of coronary CT angiography in patients with suspected coronary artery disease. Circulation Cardiovasc Imaging. 2010;3:351–9.CrossRefGoogle Scholar
  19. 19.
    Van Werkhoven JM, Cademartiri F, Seitun S, et al. Diabetes: prognostic value of CT coronary angiography – comparison with a nondiabetic population. Radiology. 2010;256:83–92.CrossRefGoogle Scholar
  20. 20.
    Naisis A, Meridith IT, Sud PS, Cameron JD, Troupis JM, Seneviratne SK. Long-term outcome after CT angiography in patients with possible acute coronary syndrome. Radiology. 2014;272:674–82.CrossRefGoogle Scholar
  21. 21.
    Galperin-Aizenberg M, Cooke TS, Hollander JE, Litt HI. Cardiac CT angiography in the emergency department. AJR Am J Roentgenol. 2015;204:463–74.CrossRefGoogle Scholar
  22. 22.
    Levin DC, Parker L, Halpern EJ, Julsrud PR, Rao VM. The lack of growth in use of coronary CT angiography: is it being appropriately used? AJR Am J Roentgenol. 2011;196:862–7.CrossRefGoogle Scholar
  23. 23.
    Goldstein JA, Chinnaiyan KM, Abidov A, et al. The CT-STAT (coronary computed tomographic angiography for systematic triage of acute chest pain patients to treatment) trial. J Am Coll Cardiol. 2011;58:1414–22.CrossRefGoogle Scholar
  24. 24.
    Levin DC, Parker L, Halpern EJ, Rao VM. Recent trends in imaging for suspected coronary artery disease: what is the best approach? J Am Coll Radiol. 2016;13:381–6.CrossRefGoogle Scholar
  25. 25.
    Litt HI, Gatsonis C, Snyder B, et al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med. 2012;366:1393–403.CrossRefGoogle Scholar
  26. 26.
    Hoffmann U, Truong QA, Schoenfeld DA, et al. (ROMICAT-II) coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012;367:299–308.CrossRefGoogle Scholar
  27. 27.
    Poon M, Cortegiano M, Abramowicz AJ, et al. Associations between routine coronary computed tomographic angiography and reduced unnecessary hospital admissions, length of stay, recidivism rates, and invasive coronary angiography in the emergency department triage of chest pain. J Am Coll Cardiol. 2013;62:543–52.CrossRefGoogle Scholar
  28. 28.
    Arbab-Zadeh A. What will it take to retire invasive coronary angiography? J Am Coll Cardiol Img. 2016;9:565–7.CrossRefGoogle Scholar

Copyright information

© Humana Press 2019

Authors and Affiliations

  1. 1.Department of RadiologyThomas Jefferson University HospitalPhiladelphiaUSA

Personalised recommendations