JACC Publication: “Current Evidence and Recommendations for Coronary CTA First in Evaluation of Stable CAD”

“If everyone is moving forward together, then success takes care of itself.”

– Henry Ford

In almost every direction we look, it is clear that things of real significance occur because a group of people align their efforts and move forward as a whole. Whether a championship sports team, a new-favorite restaurant across town, or the latest technological marvel you are holding in your hand, they are all the result of tremendous work toward a common goal.

This same marvel is happening in healthcare today. The Journal of the American College of Cardiology (JACC) published a report entitled “Current Evidence and Recommendations for Coronary CTA First in Evaluation of Stable CAD.” The authors and contributors are healthcare stakeholders representing physician societies, provider institutions, and governmental and commercial health plans.

The central tenet is that “the current aim of diagnosis of stable chest pain in patients with possible obstructive CAD must change from detection of a myocardial perfusion abnormality to detection of coronary atherosclerosis, by using a coronary CTA-first strategy.”¹ By combining physiologic information from FFR_CT with coronary CTA, clinicians can make decisions armed with powerful insights available through no other non-invasive pathway.

The challenges to making this switch are crystalized by 2016 data showing “the U.S. ratio of SPECT myocardial perfusion imaging to coronary CTA testing was 58:1” and by “perverse economic incentives, often rewarding the use of established, less effective practices as opposed to more innovative technologies offering improved medical outcomes with long-term cost reduction.”¹

The authors also point out that this imbalance is perpetuated in the US today even as data from ISCHEMIA, SCOT-HEART, and PROMISE demonstrate the clear benefits to patients of a CTA-first pathway. “Cardiovascular care in the U.S. will move forward as we ‘learn from our international colleagues’ leadership in pioneering coronary CTA–first programs. The U.K. roll-out of coronary CTA with FFR_CT demonstrates success in rapidly providing increased access with positive results in changing practice norms, improving care, and reducing costs.”¹ Physicians and clinical societies outside of the US have already implemented programs, guidelines, and education to enable and promulgate a switch to CTA-first testing and adoption of FFR_CT when indicated, and the authors call for “Collaboration among U.K., U.S., and European advisory boards [to] enhance learning and accelerate U.S. adoption.”

How can we work together to make this change? There are three main areas of work ahead of us to: “use coronary CTA as the default test for evaluating patients with stable chest pain and low- to-intermediate pre-test probability of obstructive CAD and for those with high pre-test probability of significant obstructive CAD, to rule out the presence of left main CAD, particularly when a conservative treatment strategy is selected.”¹

1. Make coronary CTA and FFR_CT easier to access. Some of the important work here will include increasing local provider expertise and competencies, allowing practicing cardiologists to become certified in coronary CTA, and eliminating insurance pre-authorizations for both CTA and FFR_CT which hinder providers from choosing a better clinical path for their patients.
2. Increase education around a coronary CTA-driven pathway. Providers such as cardiology fellows and CT technologists need more training and established quality assessments, while practicing cardiologists and primary care physicians need to know (1) for which patients they should consider coronary CTA and (2) how to use the findings in patient management.
3. Address financial hurdles driven by reimbursement. The U.S. healthcare system requires changes to more accurately reflect the value and true costs of coronary CTA and FFR_CT. This must include meaningful increases to CMS payment for this preferred pathway, as CMS reimbursement has decreased by 36% for coronary CTA and 34% for FFR_CT over the past four years. Additionally, we must continue the early successes of engaged physicians to fix financial imbalances driven by both geographic and site-of-service (hospital vs non-hospital) inconsistencies.

Improved engagement of individual physicians will increase access to a coronary CTA-first pathway locally and drive needed change nationally. To consider what role you can play in this effort, please register and join a webinar that I will be hosting on Wednesday, 16 Sept 2020 with a group of authors and contributors to this important publication.

As we work together, great changes and distinct advantages for patients and providers will be possible.

— A perspective from HeartFlow Chief Medical Officer, Campbell Rogers, MD
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1. Poon, et al. Current Evidence and Recommendations for Coronary CTA First in Evaluation of Stable CAD, J Am Coll Cardiol 2020.