re: Something to think about when you get your next CT scan

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It's never come close to actually doing this, correct??

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It worked very well, you could get cardiac CT angiography if you could find a cardiologist to order it, there were some that did. I have been away from this stuff for a few years and don't what is going on today, but at the time these systems were bought by many hospitals and imaging centers for the purpose of doing cardiac imaging, but the patients never got referred, there was a pretty focused campaign by cardiologist to make sure it never caught on, their medical association even had had study group that recommended CTA should not be used for certain types of diagnostic imaging not surprisingly it was any type of study that would replace a heart cath. It was all a big turf war, things my be different now.

I want a sex doll with a booty hole that does that

Fair enough.

Can any intervention be performed during the CTA?

In full disclosure I do both CTA and Caths. Academia may say the HR is a non issue but in practice we slow it down.

My point is that it’s not the evil cardiologist stopping great technology. It’s just not useful technology. Cool, yes but impractical.

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Haven't there been stories about magnets in the machine picking up on outside objects?

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Only from MRI machines. CTs uses ionizing radiation, not magnets.

Also, cardiac CTAs are definitely being used and have benefits, but won't be replacing cardiac caths any time soon.

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My point is that it’s not the evil cardiologist stopping great technology. It’s just not useful technology. Cool, yes but impractical.

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It was designed to be a primary screening tool with the goal of reducing the number of patients undergoing heart caths that resulted in no indication of obstructive disease. This is a portion of a article from the American College of Cardiology and indicates the value of using the technology in that manner and that the reduction could be significant.

LINK

"Cardiac CTA is more widely covered by insurance provides a method to assess not only atherosclerosis (plaque burden) but also stenosis. Cardiac CTA has now been shown to be the most accurate method to determine who has obstructive or functionally significant stenosis, affording the highest probability of requiring intervention in the cardiac catheterization laboratory.9 Unfortunately, most patients who have undergone invasive coronary angiography after functional testing reveal no obstructive disease. In national registries, only 134,670 of 302,651(44.4%) patients who underwent invasive coronary angiography following nuclear stress tests had obstructive disease.9 In the PROMISE (PROspectiveMulticenter Imaging Study for Evaluation of chest pain) trial, 72.1% of patients undergoing invasive coronary angiography after cardiac CTA had obstructive disease, compared with only 47.5% of functional-test-group patients."

I am a board certified medical physicist, you are correct in that my point of view is one from mostly research and development not the hospital. I am more than familiar with my ideas not actually working out in the real world, but given time I believe this technology along with cardiac MRI will become primary participants in the standard of care.

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A CTA can not replace a diagnostic cath.

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Cardiac CTA was never meant to replace a diagnostic Cath. Its utility is in finding lack of disease in a low-risk patient, thus preventing not only a left heart Cath, but a hospital admission/observation stay for what can effectively rule out acute coronary syndrome with a normal exam in the right patient.

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And if you do see stenosis on CTA how would you treat it?

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You don't treat coronary stenosis based off the results- you can only rule it out. When you see stenosis, you're limited to seeing an anatomic abnormality; you're unable to determine physiologic significance of lesions. I suppose you could stumble upon an occlusion, but again- the test isn't designed to be done in lieu of a left heart Cath. It's meant to be used in someone with chest pain with a low-likelihood of an acute coronary syndrome. History, physical, and EKG still rule. No one with a STEMI or a good angina story with risk factors should be getting one of these.

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so ultimately it would cost pts far more to start with CTA

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Patients who have a non-negative coronary CTA need further investigation, either with stress or Cath, depending on the story, risk factors, etc. Last I read on the subject was around 9 months ago. You're correct that the patient that has a positive coronary CTA ultimately pays more than they would have prior to the tech existing. But it's considered cost-effective because it's indicated in a certain group of patients who, traditionally, despite being low-risk were getting admitted to the hospital for 1-3 days. The money and morbidity saved from these (now lack of) stays was considered to be greater than the cost of the test when done in the right group. I'll try to find the data if you're interested.

The main reason that it hasn't caught on is
1) high cost of a more specialized CT scanner than what is widely available (and most hospitals wouldn't see a cost benefit from upgrading their CT scanner before their regularly scheduled/budgeted update, it isn't felt to really be truly saving lives or cutting edge. It merely lets the ER doc send questionable patients home instead of admitting them and can be beneficial in some primary care settings, but I'm not actually sure it's got the indication there- it was available in the city I was in before finishing residency but not at my hospital. It is not available where my new job is).
2) needs radiologist/cardiologist with special training to read it. It is labor intensive from my understanding, and it's something that many smaller (rural) centers wouldn't be able to spare the manpower for based on the availability of these specialists

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I’m not a fan of stress tests either

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They're fantastic in the right patient. An ex-lap in an obese, 40 year old g7p7 with RUQ pain without imaging could probably be justified. But that would mean a whole lot of people that didn't need a procedure got it.

Negative stress tests that proceed to cath, however, are pretty silly. And they do happen.


ETA: some data on cost effectiveness from 2010. Note the specific patient it's indicated in to be considered a cost-effective strategy (based on this study). Like I said before- I don't know exactly where the extrapolation ends.


ETA2: NEJM article on the matter. You don't really need to look further than the opening chart to see that the real value is in the negative predictive value of the test.