Expert panel recommends coronary CTA as first choice when evaluating for stable CAD

Coronary computed tomography angiography (CTA) should be the first test clinicians use to evaluate stable coronary artery disease (CAD), according to a group of specialists assembled by the American College of Cardiology (ACC).  

The ACC Summit on Technology Advances in Coronary Computed Tomography Angiography held a roundtable event in September 2019 to discuss this topic. The group’s report has been published in full in the Journal of the American College of Cardiology.

The report’s authors noted that recent evidence—including studies in both the United States and the United Kingdom—suggests a coronary CTA-first strategy can improve outcomes and “does not result in more cardiac catheterizations and revascularization.”

Getting more specialists to commit to a coronary CTA-first strategy may prove difficult at first, the authors explained, because SPECT myocardial perfusing imaging is currently much much more common.

“Transition to ‘coronary CTA first’ requires revising training programs in coronary CTA and advanced technologies to cover both coronary artery stenosis and atherosclerotic plaque, strong leadership from industry experts, and expanded certification of imaging skills to ensure consistent performance, the group wrote. “Capital investment will be critical. A national registry to monitor scan quality and medical and financial outcomes is advised.”

The ACC Summit Team also shared nine specific recommendations related to coronary CTA:

1. Begin with coronary CTA when evaluating patients with stable chest pain and “low-to-intermediate pre-test probability of obstructive CAD.” When patients have a high pre-test probability, staring with coronary CTA can also help rule out the presence of left main CAD, “particularly when a conservative treatment strategy is selected.”

2. Move cardiac CT services to the Ambulatory Payment Classification group and increase the overall payment for coronary CTA exams.

3. Consider bundled payment options for cardiac testing.

4. Investigate ways to increase the number of coronary CTA providers available to the public.

5. Update training guidelines for cardiovascular fellows, technologists and other staff members to improve overall provider competency when it comes to coronary CTA exams.

6. Begin work on a coronary CTA registry for the evaluation of chest pain.

7. Work with CMS, Congress and other applicable bodies to improve coronary CTA advocacy.

8. Engage and educate commercial providers about the importance of these exams, potentially convincing them to end required pre-approvals for coronary CTA exams.

9. Educate cardiologists and primary care physicians so that hey gain a better understanding of when—and when not—to consider coronary CTA.

Read the full report here.

A recent observational study in the Journal of the American Heart Association warned about overutilizing coronary CTA. Read more about that analysis here.