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CT Heart Scan Experts Criticize New York Times Article
President of Imaging Society "Shocked by the Article"
Featured Cardiologist's "Critical Quote Was Taken Out of Context"

July 8, 2008 (updated) -- A recent New York Times front page feature on CT angiography has produced strong reactions from cardiologists who work in the field of Computed Tomography -- reactions that range from surprise to anger. Several of the imaging specialists who were quoted in the article were particularly upset by the coverage.

Michael Poon, MD
Michael Poon, MD, FACC
President of the Society of Cardiovascular Computed Tomography (SCCT)
    Dr. Michael Poon, President of the Society of Cardiovascular Computed Tomography (SCCT), and voted one of New York's "Top Cardiologists", told Angioplasty.Org that both he and President-Elect Dr. Daniel Berman spent two hours with one of the reporters, discussing how CT could eliminate unnecessary cardiac caths and shorten ER stays, benefits that the reporter clearly understood, yet none of this information found its way into the article. They "were shocked by the article", especially the statement that the SCCT has "one purpose — to promote CT angiograms", which Dr. Poon called "a gross misrepresentation of our Society." Dr. Poon told Angioplasty.Org, "We are not advocating doing this on everybody. We are not advocating doing CTA on a patient who is asymptomatic. We have very clear guidelines."

Overuse of unnecessary medical procedures and treatments certainly is a important issue for the U.S. healthcare system and patient advocates. However, if a widely-distributed critique of CT Angiography misinterprets the facts of this procedure's value and cites only anecdotal evidence for its claim of widespread inappropriate use, it is performing a disservice for patients who might greatly benefit from this technology.

A number of cardiologists have told Angioplasty.Org that the following conclusions made in the Times article are inaccurate:

  • CT Angiography (CTA) is an unproven technology
    A number of single and multicenter clinical studies have compared CTA to the "gold standard" of invasive coronary angiography and have found CTA to be accurate, safer and cost-effective in the appropriate patients, and extremely accurate (99%) in ruling out coronary artery disease (CAD); additional trials are currently underway;
  • Physicians are using CTA needlessly on asymptomatic patients
    No data or evidence, other than anecdotal, was presented in the article to support this assertion; in the case of Dr. Harvey Hecht's patient (as previously reported by Angioplasty.Org) criticisms leveled at Dr. Hecht were unjustified because a significant piece of data was omitted from the article: his patient was not asymptomatic, as reported, but had, in fact, been experiencing chest pain -- one of the reasons Dr. Hecht recommended the CT scan; all of the published guidelines for CTA, as well as the imaging experts that Angioplasty.Org has interviewed over the past two years, including Dr. Hecht, clearly state that CTA should not be used as a mass screening tool for asymptomatic patients;
  • CTA will lead to increased testing and raise the cost of healthcare
    Experts believe that adoption of CTA actually will reduce testing. According to the most recent data, 37% of invasive cardiac catheterizations performed are negative -- they show no coronary disease; the reason most of these healthy patients end up getting an invasive cath is that they previously had gotten a nuclear stress test which indicated a possible problem (one which turned out not to exist); a 64-slice CT Angiogram is 99% accurate in definitively ruling out coronary disease; many imaging specialists believe that, if a CT Angiogram, instead of a nuclear stress test, were used as the initial diagnostic exam, two unnecessary tests (nuclear stress and cardiac cath) could be safely eliminated for hundreds of thousands of healthy patients, saving money, reducing total radiation exposure and complications from the invasive procedure;
  • Some physician practices buy scanners and use them "aggressively" on their patients to pay off their equipment costs
    This claim is unsubstantiated by any data in the article, other than anecdotal evidence; only 100 or so of the 1,000-plus CT scanners in the U.S. are installed in private practices, according to the article; as for hospitals, U.S. Census data shows 7,569 hospitals, so only about 1-in-8 even owns a scanner; additionally, according to 2005 Medicare data, only 6% of CTA referrals were self-generated, ordered by the same physician who also performed the scan;
  • The medical community has not applied best practice evidence-based medicine from a randomized clinical trial for CTA technology
    No imaging technology currently in use has been required to provide this type of outcome data. Professional societies, such as SCCT, have been established specifically to foster credentialing, training and guidelines; appropriateness criteria for CTA were published two years ago by the major cardiology and radiology organizations; the AHA just published an updated statement on June 27;
  • CTA has an excessive radiation dose
    CTA does involve exposure to radiation, which is why all the cardiologists we spoke to caution strongly against indiscriminate use; however, CTA exposes the patient to less radiation than a standard nuclear stress test which currently is the most widely used non-invasive test for CAD (some experts feel that CTA will replace much of the nuclear testing); all manufacturers of CT scanners are constantly improving the equipment and techniques and have significantly lowered the standard dose since CTA was first introduced.

Over the past week, the New York Times "Letters to the Editor" has published seven letters about the article: most were critical of CT and none challenged the accuracy of the reporting. In an effort to add an additional perspective to the reader's view of this technology, Angioplasty.Org is publishing below various comments from leading cardiologists and industry representatives. Some comments are from letters sent this week to the New York Times, but not published; others are comments made to Angioplasty.Org; still others are from full-length interviews we have posted previously in our "Imaging and Diagnosis Center".

Armin A. Zadeh MD, FACC
Armin A. Zadeh MD, FACC
Assoc. Director Cardiac CT
Johns Hopkins University
  

"People don't know that CT is not lucrative for us. It takes us a long time to read one study and reimbursement is modest. We 'd be much better off focusing on nuclear studies. Our excitement stems from the fact that for the first time we have a tool that allows us to reliably and non-invasively visualize the disease which kills hundreds of thousands Americans every year. With the traditional methods like stress tests etc., we essentially have been in the dark all along. There is no doubt in my mind that cardiac CT will forever change the way we diagnose and treat coronary artery disease.

"The supporting evidence is accumulating fast and many have trouble keeping up with the developments. Most of our scans at Johns Hopkins do not deliver more than HALF of the radiation exposure of the best nuclear stress test and much less than a thallium scan. It will take time to gather all the outcome data which will convince the skeptics but, when appropriately used, cardiac CT already saves lives today by omitting invasive procedures."


"This really is a breakthrough non-invasive imaging technology that, for the first time, gives us resolution that is adequate to evaluate the latency of human coronary arteries. We've never had a tool that could do that before without putting a catheter in.

"Compared to invasive catheterizaton, you're not going to dissect someone's right coronary. You're not going to have a retroperitoneal bleed or a piece of emboli break off the aortic wall, which happens in 1 out of 1,000 cases, and can cause a stroke. There are a number of complications that can occur from putting catheters in someone's femoral artery, and pushing catheters up around the aortic arch. The risk of all serious complications today, with good technique, is probably in the range of 0.5%, but how many millions of coronary angiograms are done? And some of the bad ones are really bad. I mean, if you get a diagnostic cath and get a retroperitoneal bleed, you could even die. So, I think that is another significant advantage of 64-slice CT. Although it might be a slightly higher radiation dose, you've eliminated the femoral access complications. All of these things happen at a very low level, but they don't happen at all with 64-slice CT."

   Tim Fischell, MD, FACC
Tim Fischell, MD, FACC
Inventor & Stent Pioneer
Borgess Medical Center
Kalamazoo, MI

Robert M. Honigberg, MD
Robert M. Honigberg, MD
Chief Medical Officer
GE Healthcare
  

"This story focuses on the use of cardiac CT angiography for patients without symptoms. Medicare only assessed the use of this technology for patients with chest pain and took into account two new large supportive studies. The technology has proven to be very accurate for showing clean arteries in patients with symptoms, which could help avoid the 25-30% rate of negative invasive angiography that burdens our healthcare system.

"So the benefits are being researched and reported, while the radiation dose is overstated. The article quotes an average radiation exposure of 21 millisieverts, but new technologies that synchronize the CT scan with the heart beat have minimized the dose to published levels of 2-3 millisieverts. Lastly, CT angiography can actually be a financial loser for cardiologists because of the relatively poor reimbursement rate. In reality, most put themselves out on a financial limb to do the right thing for their patients."


"My quote [in the Times] about 'dispensing with evidence-based medicine' was taken out of context; it should have been accompanied by the reason: which is that evidence-based medicine has never been applied to any of the other imaging technologies. Whether it's echocardiography or nuclear or stress testing or electrocardiography or chest x-rays, they've never been subjected, nor will ever be subjected, to the same criteria that is being asked for both coronary calcium and CTA.

"I also mentioned to the Times that CTA is the only non-invasive test that could have saved, not necessarily would have, but could have saved Tim Russert's life. His stress test was normal but, assuming the autopsy report was correct, he had significant multivessel disease. It's a 100% certainty that CTA would have detected this. And then would have afforded both the patient and the physician the opportunity to do something perhaps that would have saved his life. There's no guarantee, but at least they would have been acting on the basis of sound evidence."

   Harvey S. Hecht, MD, FACC
Harvey S. Hecht, MD, FACC
Dir. of Cardiovascular CT
Lenox Hill Heart & Vascular
Institute of New York

Andrew Whitman
Andrew Whitman
Vice President
Medical Imaging & Technology Alliance
  

"The story omitted peer-reviewed and emerging clinical trial data showing that CTA scans produce cost savings and improve patient outcomes. Also, for a story of this length to leave out any discussion of appropriateness criteria – even though cardiology and radiology medical societies already have programs in place, and both criteria are part of the current policy discussion – is curious. It could have also cited a recent study demonstrating how CT heart scans are an effective and cost-saving tool in selecting patients for cardiac catheterization. The selective catheterization resulted in average cost savings of $1,454 per patient.

"Proper utilization of any medical technology is important, and the majority of doctors do use medical imaging appropriately, without standing to realize any financial gain from doing so. In fact, according to 2005 Medicare claims data, an average of 94% of CT, MRI, PET and SPECT referrals are made to physicians who do not order the tests, and that percentage is even higher for cardiac imaging."


"I think there are very valid concerns out there that need to be addressed, and it's good to be somewhat careful about a new technique to avoid overuse, especially in the beginning. On the other hand, we should not be overly critical, and prevent a good method from being used clinically.

"That's why it's important to have people well-trained in cardiac CT, to use the right equipment, and to also make sure that they don't scan patients that should not be scanned. There are guidelines for competency, for what you should have done in order to perform a cardiac CT scan. These have been published by the ACC and AHA, and they call for basically 150 scans interpreted for the level 2 competency, which means that you are able to perform and interpret your own CT scans. People who want to do CT, they just have to go out there and pay attention that they get good training. If they take a course, that it's a good course with real experts teaching it."

  

Stephan Achenbach, MD, FESC, FACC
Stephan Achenbach, MD, FESC, FACC
Past President, SCCT


John McBarron Hodgson, MD, FACC
John Hodgson, MD, FACC
Past President, SCAI
  

"CMS is afraid that everybody's going to stack tests -- that you'd get a CT, then a nuclear stress test, then an invasive cath. So, in our most recent letter, we have this consortium of radiologists and interventional and nuclear cardiologists and general bodies, and everybody's in there together saying cardiac CT is good, don't mess with it! We're doing good here!

"And we now have papers that are going to be presented soon, and the data's really amazing. I mean, you can predict outcome, and we've gone on record now to say that if you have a normal cardiac CT, you do not need any other tests.

"So, that's the kind of stuff that CMS is really interested in, that we will come out and say 'Hey, if you've got a negative CT, you don't need all these other tests.'"


"There is very strong evidence that the CT coronary angiogram is the most accurate non-invasive test for the detection of coronary artery disease. Period! Nothing comes close. CT Angiography is one of the most important developments in cardiac imaging that I've seen in my lifetime. And I've had an entire career dedicated to this, for over 30 years, in cardiac imaging.

"The area that will be most affected will be the area in which tests have been used traditionally in patients with an intermediate likelihood of having coronary disease. And that isn’t the diagnostic coronary angiogram; that’s stress imaging, whether it’s a stress nuclear procedure or a stress echo procedure, or even a stress test. I think those tests may actually decline in their use for diagnosis of coronary disease. And, as the baby boomers age, there’ll be more and more in that age group. So it’s complex. There still will be diagnostic applications. There still will be a lot of use of nuclear testing. But the first test of choice in the patient with intermediate likelihood of coronary artery disease who has symptoms may well become the CT coronary angiogram."

   Daniel S. Berman, MD, FACC
Daniel S. Berman, MD, FACC
Director of Cardiac Imaging
Cedars-Sinai Medical
Center, Los Angeles

(Late Update): A three-page letter to the New York Times' editors and reporters, signed by Drs. Poon, Berman and James K. Min, Director of Cardiac Computed Tomography at New York Presbyterian Hospital, has now been posted on the SCCT website, expressing "disappointment" at the Times' coverage. The authors state, "We point to numerous statements in your article which, based upon the scientific data and prevailing expert opinion, are undeniably inaccurate, misleading or untrue."



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See a "CT Tour of the Heart"
by Dr. Harvey Hecht
   

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Founded in 1997, Angioplasty.Org is the Internet's most popular site devoted to interventional procedures. Imaging of the coronary anatomy is fundamental to the diagnosis and treatment of coronary artery disease.

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For more information, visit Angioplasty.Org's Imaging & Diagnosis Center.


About The Society of Cardiovascular Computed Tomography (SCCT)
With almost 5,000 members worldwide, the SCCT will be holding its 3rd Annual Meeting later this month. The group is a professional society, like the Society for Cardiovascular Angiography and Interventions (SCAI) or the American College of Cardiology (ACC). In fact all three organizations are headquartered in ACC's Heart House in Washington, DC. In its Mission Statement, the SCCT says it is "committed to the further development of cardiovascular computed tomography through education, training, accreditation, quality control, and research". The Society lists a large number of CT training courses on its website and President Michael Poon was on the writing committee for the 2006 Appropriateness Criteria, guidelines for the use of Cardiac CT, issued jointly by all eight major cardiology and radiology societies. For more information, visit www.scct.org.
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Reported by Burt Cohen, July 7, 2008 / updated on July 8, 2008