October 26th, 2010
Updated Appropriate Use Criteria for Cardiac CT Published
Larry Husten, PHD
An alphabet soup of medical organizations (ACCF, SCCT, ACR, AHA, ASE, etc.) have updated their appropriate use criteria for cardiac CT. The lengthy document includes an evaluation of 93 clinical scenarios and finds that cardiac CT is appropriate in 38% of them. Use of cardiac CT in the rest of the scenarios is deemed inappropriate or uncertain.
In general, cardiac CT angiography is deemed appropriate for use in patients with low or intermediate risk for CAD, while its use in high-risk patients, routine repeat testing, and general screening is deemed inappropriate. Calcium scanning is considered appropriate in people at intermediate risk or some low-risk people with a family history of heart disease.
“If we know a patient has existing heart problems or is at high risk for heart disease, doing the test isn’t generally going to add any valuable clinical information,” said Allen Taylor, the chair of the writing committee, in a press release issued by the ACC. “Ordering a test when a patient doesn’t need it — or won’t benefit — is not quality cardiac care.”
The full document is available online and will be co-published in JACC, Circulation, and the Journal of Cardiovascular Computed Tomography.
3 Responses to “Updated Appropriate Use Criteria for Cardiac CT Published”
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This CT update is a unique reference. Lots here. Still wading through it.
I feel these guidelines are inappropriately conservative and will leave a very large contingent of patients with undiagnosed heart disease until they develop symptoms. Unfortunately for over half of subjects who die from heart disease, their first symptom was their fatal event.
MESA has demonstrated that 2/3rds of women and 1/4th of men at highest risk for a coronary event are stratified as being “low risk” by Framingham. These guidelines are saying that it is OK to completely ignore half of the future heart attack victims. I disagree.
Other studies have shown that in low risk, asymptomatic screening populations, Coronary artery calcium will find that over 13% of these patients have significantly increased risk. I feel that to be wrong in assessing risk for coronary disease this often is not OK. Mammography finds cancer in less than 1% of cases, Coronary artery calcium is 13 times better when screening the “low risk” asymptomatic subjects. If you use EBT imaging, you can do the heart scan for the same radiation dose as a mammogram. 6 times more women die from heart disease than from breast cancer. How can we possibly justify mammography yearly but coronary calcium imaging never!
I think the American public would be outraged if they knew what level of risk that these guideline writers are considering acceptable.
CAC in high risk patients is also appropriate as it is a fabulous motivator for behavioral changes. I see this every day. The literature supports this, and Allen Taylor himself published on the very significant motivating value of measuring CAC. To list high risk patients as a subset for whom CAC imaging should not be done is ignoring the literature on this aspect of care.
Finally, as we are now learning that serial CIMT is of little or no value in measuring success of therapy in statin treated patients, serial EBT CAC has been shown to be a remarkably strong indicator of adequacy of treatment. I do not understand why this information is constantly ignored by the “experts”.
Competing interests pertaining specifically to this post, comment, or both:
In one week, I will celebrate 12 months without a single heart attack or ischemic stroke in my practice of 750 patients, over half are elderly and many high to very high risk patients. I could not do this without the benefit of CAC screening in Framingham “low risk” subjects as well as in “high risk subjects”.
Again, no doctor got sued for doing a test, but only for not doing one. If the patient or spouse asks for the cardiac CT test, and you refuse, and the patient drops dead from a heart attack, you will have a difficult time defending yourself before a jury. It’s similar to having a patient with asymptomatic IHSS, no dizziness or syncope, and saying the statistics don’t justify putting in an ACID in asymptomatic patients.