CT Heart Scan Experts Criticize New York Times Article
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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, FACC
President of the Society of Cardiovascular Computed Tomography
(SCCT) |
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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
Assoc. Director Cardiac CT
Johns Hopkins
University |
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"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."
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"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."
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Tim
Fischell, MD, FACC
Inventor & Stent Pioneer
Borgess Medical Center
Kalamazoo, MI |
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Robert
M. Honigberg, MD
Chief Medical Officer
GE Healthcare |
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"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."
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"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."
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Harvey
S. Hecht, MD, FACC
Dir. of Cardiovascular CT
Lenox Hill Heart & Vascular
Institute of New York |
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Andrew
Whitman
Vice President
Medical Imaging & Technology Alliance |
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"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."
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"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."
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Stephan
Achenbach, MD, FESC, FACC
Past President, SCCT
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John Hodgson,
MD,
FACC
Past President, SCAI |
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"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.'"
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"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." |
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Daniel
S. Berman, MD, FACC
Director of Cardiac
Imaging
Cedars-Sinai Medical
Center, Los Angeles |
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(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."
See a
"CT Tour of the Heart"
by Dr. Harvey Hecht |
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About the Imaging and Diagnosis
Center on Angioplasty.Org
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
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