CTA’s Rapid Expansion: Observations from SCCT 2021

Progress is not in enhancing what is, but in advancing toward what will be.

– Kahlil Gibran

Reviewing the recently completed SCCT 2021, the virtual-only annual scientific meeting hosted by the Society for Cardiovascular Computed Tomography(SCCT), was both a personal and professional pleasure. The content across two packed days provided abundant evidence of the increasing role coronary CTA is playing in the cardiovascular care pathway for patients with known or suspected coronary artery disease (CAD) today.

Some of that growth is attributable to rapid technological advances in cardiac CT that are enabling clinicians to non-invasively gather information that can be directly applied to outcome-influencing treatment decisions. Hardware advancements, such as systems now delivering “ultra-high resolution CT,” are an example of improving tools that allow clinicians to visualize important clinical details only suspected or inferred by other non-invasive tests in the past.

The discussions during SCCT 2021, however, made it clear that clinical centers can expand the role of their cardiac CT programs through accessible software and AI solutions to expand the utility and value of coronary CTA. These solutions include tools to simplify and streamline anatomic findings of plaque and stenosis severity throughout the coronary tree or to assess non-invasively the physiologic impact of CAD via FFR_CT. As they looked forward, the leaders in the field spoke of how the use of artificial intelligence (AI) will aid clinicians in identifying high-risk CAD and, once evidence of impact on outcomes is obtained, allow optimized management.

Another area of growth has been the marked increase in clinical research involving coronary CTA. As noted by Dr. Todd Villines, editor-in-chief of the Journal of Cardiovascular CT (JCCT), the 12 months from July 2020 to July 2021 have seen the release of approximately 9,000 clinical publications involving coronary CTA, bringing the historical total to nearly 100,000 publications. This encapsulates a wide range of publications ranging from individual anomalous case reviews to large randomized controlled trials, and the sheer volume speaks to the central focus on coronary CTA that has emerged within the research community.

While it is exciting to see the clinical evidence build beyond what is available for any other non-invasive cardiac test, the growing ways in which patients are being served by coronary CTA is even more striking. Of the outstanding data presentations, some stood out as they spoke to the expansion of a CT+FFR_CT pathway. For example:

• Allegheny Health (PA) clinicians reported how this pathway “significantly improved ICA yield with a lower false positivity rate in acute chest pain patients who present to the emergency room.”
• Lundquist / UCLA (CA) clinicians gathered a “combination of vessel volume, positive remodeling, plaque length, and necrotic core volume” data from coronary CTA to examine how CAD changes over time.
• St. Francis Hospital (NY) clinicians assessed over 1,000 patients and found that in many with “high prevalence of obstructive stenosis and adverse plaque features, FFR_CT in the range of 0.81-0.85 should be further investigated as an indicator of possible subclinical disease.”
• UT Southwestern (TX) clinicians explored the use of CT+FFR_CT in a small group of pediatric patients status post heart transplantation and found it to be “feasible” and that it “might add value to augmenting the screening process for CAV and improve medical management with early detection.”
• Massachusetts General Hospital (MA) clinicians reported that FFR_CT fit well into their existing pathway such that “using our standard coronary CTA protocols, no studies were rejected for FFR_CT analysis.”

Clinical data released at the SCCT meeting reinforces a refrain from ACC.21 that the anticipated ACC/AHA Practice Guidelines for the Evaluation and Diagnosis of Chest Pain should elevate coronary CTA as a frontline test for patients with suspected CAD. As Dr. Ron Blankstein from Brigham and Women’s Hospital and immediate-past president of the SCCT observed, these clinical guidelines provide an opportunity to guide selection of the most appropriate diagnostic modality and to highlight how imaging findings can inform therapy.

SCCT 2021 reminded us how the clinical data are evermore irrefutable that for non-ACS patients with symptoms suggestive of CAD, coronary CTA is the path to optimally informed treatment and improved long-term outcomes as compared to other available options.

— A perspective from HeartFlow Chief Medical Officer, Campbell Rogers, MD
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