COVID-19 pandemic may play critical role in increased CTA use
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The COVID-19 pandemic poses several challenges for cardiac care but may be an opportunity for coronary CTA to be more widely used, according to presentations at the Society of Cardiovascular Computed Tomography Annual Scientific Meeting.
Opportunities, challenges with coronary CTA
The role of coronary CTA during the COVID-19 pandemic depends on the stage of disease. For the acute stage of the disease, clinicians will ask whether patients have ACS or myocardial injury.
“This is an important question because 10% to 30% of patients with COVID who are admitted have elevated troponin markers,” Ron Blankstein, MD, MSCCT, FASNC, FACC, FASPC, director of cardiac computed tomography, associate director of the cardiovascular imaging program and associate physician of preventive cardiology at Brigham and Women’s Hospital, associate professor of medicine and radiology at Harvard Medical School and president of the Society of Cardiovascular Computed Tomography (SCCT), said during the presentation.
In the chronic stage of the disease, coronary CTA may be used to evaluate patients who have chest pain, potentially new left ventricular dysfunction or new arrhythmias.
A case series published in The New England Journal of Medicine in June found that 18 patients with COVID-19 and STEMI did not have coronary disease, but rather ST elevations from myocardial injury.
The SCCT developed and published a guidance document in the Journal of Cardiovascular Computed Tomography on when to use cardiac CT during the pandemic. This suggests that coronary CTA may be used in carefully selected patients with elevated cardiac enzymes, symptoms of ACS and an inconclusive ECG to exclude obstructive CAD. In addition, this document states that the use of coronary CTA should only be considered when diagnostic quality imaging can be achieved.
“This is important because not all patients with elevated enzymes are going to be good candidates for coronary CTA, so we have to be selective,” Blankstein said.
Similar recommendations were made in a statement by the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions and the American College of Emergency Physicians. Guidance from the European Society of Cardiology states that coronary CTA is preferred in patients with acute chest pain and suspected obstructive CAD.
The VERDICT trial published in the Journal of the American College of Cardiology this year assessed the use of coronary CTA in patients with non-ST-elevation ACS. In patients with ACS, approximately 30% had no stenosis, and CTA had a high negative predictive value of 91%.
Blankstein said a common symptom after recovering from COVID-19 is chest pain.
“As these patients now have chest pain, a question that all of us will be facing is how do we evaluate them further,” Blankstein said.
When there is a clinical suspicion of CAD, CT, MRI and nuclear cardiology all have important roles, but CTA can play a bigger role in patients with no known CAD who have symptoms of possible angina or to identify patients with CAD who can be treated in a conservative manner, according to the presentation.
Not only does coronary CTA benefit patients with COVID-19, but also those who test negative as it can help to avoid unnecessary admissions and invasive angiography, and to identify patients with CAD who can be treated conservatively.
Impact of COVID-19 pandemic
In another presentation, Jonathon Leipsic, MD, FRCPC, MSCCT, professor of radiology and cardiology and vice chairman of radiology at the University of British Columbia, Canada, research chair of advance cardiac imaging and past president of the SCCT, discussed how important coronary CTA can be during the pandemic.
“Cardiac CT is an incredibly valuable test,” Leipsic said. “Some of you have even called me a ‘CT zealot,’ but the reason I’m so zealous about cardiac CT is not because I think it should be used for every indication ... but I do think that when you reflect on what the question is being asked, that in the era of COVID more than ever, that COVID needs to serve as a crucible for change. We need to do the right test at the right time for the right patient, and we shouldn’t just follow our historical algorithms for workup and management of patients because that’s what we used to do, and we certainly need to be avoiding layering of testing when at all possible.”
Leipsic said the strongest support for cardiac CT from an international society came from a guidance document from the ESC. This document highlights that although other testing can play a role in the acute phase, CTA should be the preferred noninvasive strategy during the pandemic.
With regard to safe reintroduction of invasive CV procedures and diagnosis tests, practices and health care professionals alike should consider the prevalence of COVID-19 on their specific area.
“Clearly, how we test and how we approach testing in patients will very much depend on the overall community spread and the disease burden in the populations we’re serving,” Leipsic said.
Coronary CT should be explored beyond its usual applications, according to the presentation. This may include guiding transcatheter mitral interventions, in addition to understanding leaflet morphology and annular landing zone related to left atrial appendage closure.
“Historically, we may have wanted to do two tests, but perhaps now we have to consider getting by with just one, and one that doesn’t involve invasive procedures and doesn’t risk aerosolization,” Leipsic said.
According to a recent ACC imaging council statement on multimodality CV imaging during COVID-19, coronary CTA may have advantages in the deceleration phases of the pandemic regarding safety, efficiency and resource utilization. The statement also addressed the importance of identifying patients with CAD who can be treated conservatively.
Expanded opportunities for cardiac CT include left atrial appendage closure, infective endocarditis, for anatomical and functional evaluation without repeat testing, and an expanded role for non-STEMI evaluation, according to the presentation.
“All of the amazing data that have been generated by so many within our society and globally, we will see that people like our interventional colleagues will start looking toward CTA, given the fact that they don’t want to be taken to the cath lab, patients who aren’t going to derive a benefit,” Leipsic said.
Coronary CTA can also play an expanded role in transcatheter aortic valve replacement, as it can identify patients who do not need to undergo invasive coronary angiography before TAVR.
“We need to have a more robust preprocedural evaluation of the anatomy and the physiology, and I believe that we can potentially do this with CT, but we’re going to need to optimize our image quality,” Leipsic said.
For the latest news on COVID-19 including case counts, information about the global public health response and emerging research, please visit the COVID-19 Resource Center on Healio.
References:
- Bangalore S, et al. N Engl J Med. 2020;doi:10.1056/NEJMc2009020.
- Choi AD, et al. J Cardiovasc Comput Tomogr. 2020;doi:10.1016/j.jcct.2020.03.002.
- European Society of Cardiology. ESC Guidance for the Diagnosis and Management of CV Disease During the COVID-19 Pandemic. https://www.escardio.org/Education/COVID-19-and-Cardiology/ESC-COVID-19-Guidance.
- Linde JJ, et al. J Am Coll Cardiol. 2020;doi:10.1016/j.jacc.2019.12.012.
- Zoghbi WA, et al. JACC Cardiovasc Imaging. 2020;doi:10.1016/j.jcmg.2020.06.001.
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Blankstein R.
Leipsic J. Cardiac CT in the COVID Pandemic. Both presented at: Society of Cardiovascular Computed Tomography Annual Scientific Meeting; July 17-18, 2020 (virtual meeting).
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