September 8, 2020

SCCT Announces Report Recommending CTA-First Approach for Stable CAD

September 8, 2020—The Society of Cardiovascular Computed Tomography (SCCT) announced the publication of a report, “Current Evidence and Recommendations for Coronary CTA First in Evaluation of Stable Coronary Artery Disease,” that outlines the benefits of coronary CTA as a first-use strategy in treating stable coronary artery disease (CAD).

The document, which also discussed the challenges and barriers related to a CTA-first approach, was published by Michael Poon, MD, et al in Journal of the American College of Cardiology (JACC; 2020;76:1358-1362).

According to SCCT, the report reflects the expert consensus of attendees at the American College of Cardiology (ACC) Summit on Technology Advances in Coronary Computed Tomography Angiography that was held on September 18, 2019. In the document, Dr. Poon et al noted that despite evidence that a coronary CTA–first strategy can improve outcomes and may lower cost for patients with stable chest pain, the ratio of nuclear single-photon emission CT myocardial perfusion imaging to coronary CTA testing is 58:1 in the United States.

Additionally, the report provides evidence from the SCOT-HEART and PROMISE trials, as well as early reports from the ISCHEMIA trial.

The statement in JACC outlines data demonstrating that for patients who do not have known CAD, the detection of CAD should change from detection of a myocardial perfusion abnormality to detection of coronary atherosclerosis through a CTA-first strategy. The United Kingdom and the rest of Europe have changed their guidelines as a result of this evidence.

SCCT President Koen Nieman, MD, stated in the press release, “In countries around the world, cardiac CT has been adopted as a first-line diagnostic test in patients with stable chest pain, and I have no doubt this strategy will be embraced in the United States as well if appropriate conditions can be established.”

Ron Blankstein, MD, SCCT Immediate Past President and part of the planning committee for the ACC Summit, commented in the announcement, “The available evidence suggests that a coronary CTA–first strategy can provide important benefits to our patients, yet there are barriers to wider implementation, including inadequate payment, insufficient number of imagers (both cardiologists and radiologists) trained to interpret these tests, and a need for more education of referring physicians on when and how to utilize coronary CTA in patient care.”

Per the report, CT scanners are widely available, but the challenges of shifting from other forms of imaging to coronary CTA include the need for more education and training of medical professionals to produce high-quality imaging, in addition to higher reimbursement and improved insurance preauthorization. As outlined in the press release, the ACC Summit attendees recommended the following steps to move toward adopting a CTA-first strategy:

  • Use coronary CTA as a first-line test for evaluating patients with stable chest pain and low-to-intermediate pretest probability of obstructive CAD.
  • Increase payment for coronary CTA and improve advocacy for coronary CTA by direct engagement with public and private payers.
  • Explore options for “bundled payments” for cardiac testing.
  • Identify expert and financial support to increase the number of capable coronary CTA providers.
  • Develop strategies to improve provider and delivery team competency in performing coronary CTA.
  • Establish an ACC coronary CTA registry for evaluating chest pain. This registry could include medical and economic variables to evaluate “total cost of care” associated with coronary CTA.
  • Engage commercial payers in discussions on eliminating preapprovals for coronary CTA and fractional flow reserve CT for providers participating in the coronary CTA registry.
  • Improve education of cardiologists and primary care physicians on when to consider coronary CTA testing versus other techniques.


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