September 11, 2020
“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 (ACC) published a statement 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 recommendation 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 FFRCT 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 in the recommendations 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 recommendations 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 FFRCT 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 FFRCT when indicated, and the recommendations include a 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 in order to follow the #1 recommendation, which as stated is 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
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 ACC Summit Statement.
As we work together, great changes and distinct advantages for patients and providers will be possible.
1. Poon, et al. Current Evidence and Recommendations for Coronary CTA First in
Evaluation of Stable CAD, J Am Coll Cardiol 2020.