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June 29, 2008 -- 1:45pm EDT

Misleading Report on CT Heart Scans
For those in the cardiac imaging field who felt a sense of relief in March when Medicare decided against eliminating coverage for most CT angiograms, don't spoil your summer weekend by glancing at this morning's New York Times.

The lead headline above-the-fold, front-and-center story, sporting a big 5x7 color photo, screams out: "Weighing the Costs of a CT Scanís Look Inside the Heart -- CT Scans Give Doctors Financial Incentive, But Medical Benefits Are Unproven".

   64-slice CT scan

The headline is a point-of-view give-away: those money-grubbing docs, needlessly exposing their patients to dangerous radiation just to make a buck! (Odd that this article would appear in the midst of a giant political battle on Capitol Hill over big Medicare cuts for physicians.)

It's a lengthy article and includes quotes from many sources. The authors, Alex Berenson and Reed Abelson clearly did a lot of legwork, but they vaulted over significant pieces of information that would definitely muddy up their thesis.

Evidence-Based Medicine
The article states that CT Angiograms (CTA) have not been studied in a randomized clinical trial to show that they positively affect patient outcomes; therefore their benefits remain unproven. But this benchmark has never been applied to any of the currently-used imaging technologies, ever -- (see Dr. Harvey Hecht's editorial in a recent American Journal of Cardiology, "The Deadly Double Standard").

Radiation Risk
The authors discuss the radiation exposure from CTA a number of times, yet fail to note that the radiation dose from the widely-used nuclear stress test is the same, if not higher. Moreover, this past year has seen numerous advances to significantly cut the dose for CTA.

CTA Will Lead to More Testing
Actually, the opposite effect is cited by many imaging specialists who point to the fact that more than a third of the million invasive cardiac catheterizations currently performed annually in the U.S. are negative: the arteries are clear, the patient has no disease.

So how do these patients with no disease wind up on the cath lab table? Very often because of false positives from nuclear stress tests, often in women. Multislice CT Angiograms are 99% accurate in identifying patients with no coronary disease (see the CorE 64 study) so in many of these cases, both a nuclear stress test and invasive catheterization could have been avoided by using a single non-invasive less-risky test: the CT angiogram.

Use of CTA is Indiscriminate
A big section of the article, cutely titled "Impatient Patients", is devoted to the patient in the front page photo, Mr. Robert Franks, who had a strong family history of fatal heart disease (a father and two uncles). We are told he is basically healthy and on statins which helped get his LDL to 60, he had a clean nuclear stress test, but a somewhat-elevated calcium score. The patient wanted a CT Angiogram, and Dr. Hecht of Lenox Hill Hospital agreed. The "appropriateness" of this decision becomes the subject of a "debate" between Dr. Hecht and Dr. Ralph Brindis, head of cardiology for Kaiser in Northern California. Brindis reportedly states that Hecht had erred in prescribing an unnecessary test, and is quoted as saying, "...the concept of doing serial CT testing on asymptomatic patients, I think, is abhorrent. I cannot justify that. "

But here's what we are not told. The patient was experiencing chest pain which, according to Dr. Hecht (I contacted him), was one of the major reasons for the CT scan, especially in light of the clear stress test. The New York Times never mentions this critical symptom -- not to its readers, and perhaps not to Dr. Brindis. One would have to wonder why?!

Did not the authors' colleague, Tim Russert, who also had an elevated calcium score, pass his stress test with flying colors just a month before his fatal heart attack? His doctor told NBC that the autopsy showed "significant coronary artery disease in the Left Anterior Descending coronary artery." 15 minutes in a CT scanner would have revealed this -- the scan wouldn't have prevented the tragedy, but the elevated risk it indicated perhaps could have been treated more aggressively.

Industry is Pushing CT Inappropriately
I'll only point out here that the authors cite "evidence" that industry is behind the CT push by painting a picture. They write, "As more than 13,000 heart doctors gathered in Chicago in late March for the annual American College of Cardiology conference, the biggest and best-located booths belonged to General Electric, Philips Electronics, Siemens and Toshiba, the leading makers of the machines used for CT angiograms."

I might point out that these four companies also manufacture and display every imaging device and modality used by all cardiologists, from full-blown catheterization labs (which take up the majority of their exhibit space) to X-ray units, MRI systems, ultrasound devices and yes, even nuclear stress units. They have very large booths, because all this equipment is...well...very large!

Finally, a personal peeve is that the article implies that Dr. Hecht and other CT enthusiasts are opportunists or cowboys, hitching to a new and untried technology, when the fact is that many of these imaging specialists have been in practice for several decades, and their opinions about CT are founded in their experiences with other imaging technologies.

Of course any new technology can be overused, abused, applied incorrectly, etc. That's not what we're talking about here. We're talking about an important imaging technology that has been studied, discussed, compared, complete with Appropriateness Criteria guidelines issued jointly two years ago (!!) by all the professional cardiology and radiology societies. The leaders in this field, including the founding members of the Society of Cardiovascular Computed Tomography (SCCT), are very concerned that this technology is used appropriately and their concerns are reflected in the series of interviews we publish in the "Imaging and Diagnosis" section on Angioplasty.Org

Dr. Hecht, in particular, was involved in the pioneering stages of coronary angioplasty, when he was assessing the results of balloon dilatation with nuclear scans. As he states at the close of his interview on Angioplasty.Org, "I have a huge background in both nuclear and stress echocardiography, and CTA is simply a better test. It's time to move to the better test."

And now, back to my weekend....

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