Revascularization rates higher with ‘CT first’ diagnosis of chest pain
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Key takeaways:
- A “CT first” strategy was tied to higher revascularization rates vs. other tests for chest pain.
- CABG or PCI was lower after stress echocardiography, myocardial perfusion imaging, MRI or no testing vs. CT.
Read-world data showed that more patients underwent subsequent revascularization after “CT first” evaluation for chest pain vs. other functional testing strategies, researchers reported.
“Right now, when a patient presents to their primary care physician or cardiologist with symptoms suspicious for angina, they are commonly referred for additional testing,” Markus Scherer, MD, director of cardiac CT and structural heart imaging at Atrium Health-Sanger Heart & Vascular Institute, said in a press release. “Cardiac catheterization labs are a capital and human resource intensive care environment. Using them for their maximum potential of treating disease, rather than diagnosing it, bring the highest yield for these resources to the health care system.”
Data were derived from Downey WE, et al. Quality improvement. Presented at: American College of Cardiology Cardiovascular Summit; Feb. 1-3, 2024; Washington, D.C.
In 2021, the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines published the first recommendations for the evaluation and diagnosis of chest pain symptoms in the ED.
In the new guideline, the committee designated coronary CT-based fractional flow reserve (HeartFlow FFRCT Analysis, HeartFlow) as a class 2A recommendation in four categories for the diagnosis of chest pain.
Scherer, William E. Downey, MD, FACC, medical director of interventional cardiology at Atrium Health-Sanger Heart & Vascular Institute, and colleagues conducted the present study to assess whether the “CT first” strategy for the diagnosis of chest pain in patients with no history of CAD, compared with functional testing or no testing, affected subsequent rates of revascularization after invasive coronary angiography.
The results of the study were presented at the ACC Cardiovascular Summit.
From Oct. 3, 2022, to June 30, 2023, 786 consecutive patients (mean age, 66 years; 63% men; 81% white) underwent elective invasive coronary angiography for chest pain.
Overall, 44% of patients received no testing before angiography, whereas 3% received stress echocardiography, 15% received stress myocardial perfusion imaging, 2% received stress MRI and 36% received coronary CT.
The researchers reported that 62% of patients who received the “CT first” approach for the evaluation of chest pain subsequently underwent revascularization with CABG or PCI, whereas 34% of patients from the other strategies (range, 31% to 50%) underwent revascularization.
“While care must be individualized, for patients with unknown or unestablished coronary artery disease, the transition to a ‘CT first’ strategy should be a high priority for cardiovascular care providers,” Scherer said in the release. “The noninvasive approach has a lower risk and cost than a diagnostic heart catheterization and, for the CT approach — but not stress testing — provides information on the absence, presence and extent of coronary atherosclerosis and whether or not there are high-risk plaques as well as vessel blockages, which helps streamline patient management and risk reduction.”
Reference:
- CT scan is most effective to assess people with chest pain. https://www.acc.org/About-ACC/Press-Releases/2024/02/01/15/39/CT-Scan-is-Most-Effective-to-Assess-People-with-Chest-Pain. Published Feb. 1, 2024. Accessed Feb. 1, 2024.
Perspective
Back to TopThe American Society of Nuclear Cardiology and many other professional medical societies strongly support research aimed at improving test selection and facilitating patients’ access to the best available tests to guide their care. ASNC advocates for patient-centered care and believes that a “one-modality-first” approach does not support patient-centered care.
Diagnostic testing for chest pain as outlined in the 2021 ACC/AHA chest pain guideline can be accomplished by multiple different imaging modalities. We must keep in mind factors such as local expertise, access to modern imaging equipment and individual patient characteristics when deciding the right test for the right patient at the time it is needed.
For the population evaluated in this study, the “CT-first strategy” reflected a retrospective study of patients who had cardiac CT angiography first in their cardiac evaluation prior to coronary angiography. The study does not address the many factors that would have gone into selecting which imaging test each patient had prior to angiography, how many patients had imaging testing but did not undergo coronary angiography, nor the impact of the test results in choosing which patients would undergo further testing. These data are needed to determine how the study might play a role in further delineating individualized testing selection in the future.
This study also underscores the importance of lab modernization — a continuous focus for ASNC. The growth we are seeing in cadmium zinc telluride single-photon emission CT and cardiac PET continues to support ASNC’s goal of high-quality imaging and subsequent improvement in decision making for patient care.
As we look to the future and forthcoming professional society guidelines, ASNC is excited to collaborate with our cardiology and cardiac imaging partners and will continue encouraging research to inform the selection of the most appropriate diagnostic testing for the individual patient.
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Downey WE, et al. Quality improvement. Presented at: American College of Cardiology Cardiovascular Summit; Feb. 1-3, 2024; Washington, D.C.
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