The American College of Cardiology (ACC) Summit Team released recommendations regarding the use of coronary computed tomography angiography (CTA) as an initial tool for the diagnosis of stable coronary artery disease, which were published in the Journal of the American College of Cardiology.
The standard diagnostic tool for patients with stable chest pain in the United States is functional imaging. However, results from recent randomized clinical trials suggest a coronary CTA-first approach may be superior.
Current evidence indicates that CTA does not cause more cardiac catherization or revascularization, and that it is not associated with increased 5-year invasive interventions. In addition, CTA is associated with lower healthcare cost, leading the United Kingdom and European societies to recommend CTA first y for the diagnosis and management of chronic coronary syndromes.
Despite the most up-to-date evidence, and recent guideline shifts in other countries, adoption of this policy may be particularly challenging in the United States due to concerns related to equipment, education, and funding.
Nuclear medicine cameras and stress echocardiography laboratories are not widespread in the United States.
Despite this fact, the ACC Summit Team does highlight that CT scanners are ubiquitous across the US. They cite recent trials (eg, PROMISE) which have established that CTA may be feasible at nonexpert sites.
American educational programs have focused on functional over anatomic testing, leading to a scarcity of required technical expertise to integrate such practices country-wide.
Transitioning to a CTA-first policy will require revising training programs, the ACC Summit Team cautions, which should include continuing education programs for practicing clinicians. Revised programs will need to feature expanded certification of imaging skills. Furthermore, all cardiologists and primary care physicians require education on when coronary CTA should be considered over other techniques and how to interpret and integrate results into patient care.
The authors of the document also recommend the implementation of a national registry which would ensure consistent quality for patients.
The American insurance system causes reimbursement disparities between testing modalities despite similar costs.
To address this issue, the ACC summit Team recommends that a CTA procedure should be reclassified to the Ambulatory Payment Classification group for increased reimbursement. The assessment of value-based and shared-savings models should be investigated to reduce more costly diagnostic procedures and to justify a CTA-first policy results in long-term cost reduction. Direct advocacy will be needed with both public and private payers to establish equitable payment and to eliminate the need for pre-approval permission before a CTA procedure.
Regardless of potential implementation difficulties, the most current research indicates a clear benefit of a CTA-first policy for patients. Therefore, the ACC Summit Team recommends CTA as the default evaluation tool for patients with stable chest pain and for the assessment of obstructive coronary artery disease.
They further stress that collaborations between the United States and the leadership responsible for the roll-out of the CTA-first policy in Europe may allow for enhanced learning and a more rapid adoption of this practice throughout the United States.
Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.
Poon M, Lesser J R, Biga C, et al. Current evidence and recommendations for coronary CTA first in evaluation of stable coronary artery disease. J Am Coll Cardiol. 2020;76(11):1358-1362. doi:10.1016/j.jacc.2020.06.078