CCTA: Radiology Prepares

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Though expertise and reimbursement lag, many radiology practices gear up to perform their share of a potential 20 million procedures a year

The potential market for coronary CT angiography (CCTA) continues to grow as new CT scanners offer improved visualization of the coronary arteries and reduced radiation exposure. At the same time, the obstacles have proven stubborn. While radiologists in academic centers, hospitals, and private practice prepare to use the technology to image the vessels of the heart, they are frustrated by barriers to reimbursement and stymied by turf disputes. Mass-media attention to the controversial practice of self-referral by cardiologists ordering CCTA has also brought to light the need to balance the benefits of advancing technology with rising health care costs. Some radiologists believe that until these issues are resolved, CCTA will not fulfill its potential to improve the medical management of cardiac disease—and, ultimately, patient outcomes.

Potential Market Analysis

Jack M. Ziffer, MD, PhD, is director of cardiac imaging, Miami Vascular Institute at Baptist Health, Miami, and chair, Radiology Associates of South Florida. He estimates that the potential for CCTA in US market is 10 to 20 million examinations per year. He bases this estimate on the current number of nuclear cardiology studies done per year: 10 million. “A substantial number of those patients would be well served by CCTA as the first type of evaluation,” he says, adding that the potential number of CCTA exams doubles, given the availability of better imaging and reduced radiation dose made possible with newer scanners.

Ziffer notes that a preponderance of clinical evidence supports the use of CCTA to diagnose and manage coronary disease. In addition, the new generation of technology will help evaluate a growing population of aging patients with asymptomatic heart disease, diabetes, or siblings with premature heart disease or sudden death. “It can establish whether they have coronary disease or not, and more aggressive management could take place,” he emphasizes. “Data need to be developed to evaluate whether imaging of these high-risk, asymptomatic patients is, in fact, beneficial.”

"We have a tremendous opportunity; it is the beginning of a potential major shift in how patients are evaluated, with nuclear scans currently being the mainstay. It is an incredibly exciting time to be part of the field."
-Jack M. Ziffer, MD, PhD Miami Vascular Institute/Radiology Associates of South Florida

He adds, “We have a tremendous opportunity; it is the beginning of a potential major shift in how patients are evaluated, with nuclear scans currently being the mainstay. It is an incredibly exciting time to be part of field,” he says, particularly as it develops the right approaches and avoids applying others where there is no benefit.

David Dowe, MD, of Atlantic Medical Imaging in Galloway, NJ, agrees that there is huge potential for CCTA. “The potential is equal to the number of stress tests that are done,” he says. “CCTA is proving to be an equal test, or superior to stress tests, for detecting stenotic disease.”

Ethan J. Halpern, MD, MS, professor of radiology and urology at Thomas Jefferson University, Philadelphia, concurs that the number of patients for whom CCTA is appropriate is increasing as the technology improves. “We can get better resolutions on patients who have higher heart rates and higher arrhythmias,” he notes. With the new technology, radiation dose is coming down dramatically, lowering barriers to the use of CCTA to provide the same information gained from a nuclear stress test.

In fact, the emergency department (ED) at Jefferson employs a triple rule-out protocol. Halpern cites a recent study on the practice, published in Radiology, that describes the outcomes of 200 patients, presenting in the ED with symptoms suggesting acute coronary syndrome, who underwent CCTA. Takakuwa and Halpern¹ found that 76% of the patients were discharged from the ED after the study.

“These are people who otherwise would probably have had a nuclear study,” he emphasizes. Another benefit was that, for a population with an intermediate risk for acute coronary syndrome, the test found extracardiac anomalies in 11% of the patients that might not have been picked up on other tests. This is a patient population in which CCTA has a role in finding an anomaly more quickly, and it can be done without having to control heart rate