When you shift your focus, you change your life.
– Steve Rizzo
November 2021 provided a veritable tsunami of learning for clinicians with any passing interest in cardiovascular disease and treatment. The month included TCT 2021, the AHA Scientific Sessions, and RSNA 2021. Additionally, these meetings were preceded by the late-October release of the ACC/AHA Guideline for the Evaluation and Diagnosis of Chest Pain which elevated the role of coronary CTA and led to many discussions around improving daily patient care.
As always, TCT, AHA, and RSNA provided rich content to help us make informed treatment decisions for our patients with severe cardiovascular disease. For example:
- FAME III, OPTIMUM, RAPID CABG, and PALACS inform us as we consider advances in cardiac surgery techniques and patients appropriate for surgery.
- PARTNER 3, AVATAR, and SURTAVI allow us to better assess the choices we make for patients who are likely to benefit from less-invasive structural heart procedures.
- GUIDE-HF, EMPEROR-Preserved, CHIEF-HF and others help to illuminate treatment approaches for heart failure patients.
These late-breaking clinical trials exemplify the remarkable clinical trial work that is advancing complex cardiovascular care in an unparalleled fashion. Such patients have vastly better treatment options than their counterparts from ten or 15 years ago.
But what if the next decade of advancement is also notable for reduction in the incidence of advanced cardiovascular disease rather than just for how to better treat patients with disease? Of course, we will continue to discover and prove improved treatments, but what if fewer patients needed those options because they were identified earlier in the course of disease and therefore better cared for before clinical manifestations appeared? The staggering numbers of patients in the early stage of disease indicate this is a significant opportunity.
Suppose that this is the gauntlet laid before us by the ACC/AHA Chest Pain Guideline authors: to hone the tools that we use to initially assess patients for nascent coronary disease. The notable elevation of coronary CTA in coronary artery disease (CAD) assessment is central to that. Clinical trials have demonstrated that outcomes are improved through earlier disease detection driven by coronary CTA because clinicians can focus on providing care to impact outcomes. However, this opportunity for early, outcome-changing care can be missed if (1) sites are bogged down testing low-risk patients whose tests are almost certain to be negative, or (2) suboptimal test modalities are used that overlook disease likely to benefit from early attention.
Emphasizing this point during an AHA session discussing the Chest Pain Guideline, Stephen Wiviott, MD, FACC pointed out that “[clinicians] want testing that is believable and actionable… If it is not likely that an individual test would result in a change of therapy, and that a positive test might even be disregarded based on pre-test probability, then there is no benefit to the patient.”
The message of focus arose again and again during TCT, AHA, and RSNA. Whether in the clinic, ED, cath lab, or OR, clinical efforts are in use to ensure that patients who can benefit from the care specific to each of those environments has a pathway to get there while the remaining patients are appropriately redirected to other treatment options. This work will be simplified as clinicians embrace the approaches within the new ACC/AHA Chest Pain Guideline, including a coronary CTA + FFRCT pathway, to enable better informed treatment decisions sooner.
Looking ahead, I believe that work to prevent advanced CAD via earlier detection and treatment will be the foundation for improved cardiovascular care in the years ahead, even beyond the exemplary efforts highlighted in these meetings to better treat patients with advanced disease.