The Role of CCTA in Primary Care

Primary care physicians are increasingly referring patients for coronary CT angiography (CCTA) to provide accurate diagnosis of coronary artery disease (CAD) and earlier disease management for their patients. Most practitioners recognize the benefits of CCTA for those who are at risk of coronary disease, as well as for patients who exhibit related symptoms. Still, clearing the way for these patients to take advantage of the advancing technology has been fraught with roadblocks. Although the technology has been available for years, it wasn’t until recently that CCTA was confirmed as providing more accurate information on the progression of coronary CAD than that provided by other diagnostic cardiology tests. In fact, a report in the American Journal of Cardiology for March 15, 2008, found that 64-slice CCTA has superior sensitivity and specificity in diagnosing obstructive CAD, compared with stress testing. “CCTA blew the doors off stress testing,” David Dowe, MD, a radiologist at Atlantic Medical Imaging in Galloway, NJ, explains. “In the last month, we now have medical justification to provide to the insurance companies. CCTA should be the first-line test when examining patients expected to have CAD,” he emphasizes. Dowe reports that 60% of his radiology department’s referrals for CCTA are from primary care physicians. About 10% come from cardiologists, while the remaining referrals are from hospitalists, nurse practitioners, and self-referrals. He estimated that in 2007, his department did 2,000 to 3,000 CCTAs, and he expects a growing demand for the diagnostic test. “It is an everyday exam,” he says. “We are further along down the road; it is becoming mainstream.” Initiating the Education Process Radiologists and hospitals already have begun working with primary care physicians to educate them on the benefits of the technology. At St Vincent’s Hospital in Indianapolis, medical liaisons are meeting with primary care doctors in their offices and distributing informational brochures, as well as hosting seminars to demonstrate the results shown in CCTA, according to Gary Fammartino, senior vice president of outpatient and ambulatory services at St Vincent. As primary care physicians order more CCTA and review the results, they are more inclined to integrate this diagnostic tool into their practices. “We are coming out of the black box. We now have a noninvasive test with better diagnosis,” Dowe says. Primary care physicians can now do preventive work with patients to manage the disease, without always having to refer them to a specialist. A major challenge for these physicians is to win the precertification war with the insurance companies, which until recently haven’t readily offered reimbursement for the test. Dowe acknowledges that some primary care physicians are “throwing their hands in the air” and recommending the more conventional stress tests, rather than facing the brick wall of nonreimbursement. There are, however, glimmers of a change in attitude as insurance coverage varies regionally, he notes. Still, he believes that insurance companies, in time, will see that the tests will have long-term, bottom-line benefits, eliminating the need for more invasive and expensive cardiac testing. Phil Feitelson, MD, an internist from Louisville, KY, agrees that insurance companies are currently shortsighted when it comes to covering the costs of CCTA. “If you get a false positive or false negative [from a stress test], it is a waste of money,” he explains, adding that patients don’t want to start taking cholesterol-lowering medication based on those results because of concerns about side effects. “When we show them the results from the CCTA, however, it gets their attention, and they are more likely to get treated. To me, it is convincing when I can show them a lesion that can cause blockage. The smaller blockage is not so benevolent anymore,” he adds. Further, CCTA is particularly helpful for patients in their 40s or 50s who have risk factors such as family history, but aren’t inclined to do anything until you show them advancing disease. Feitelson says that when he shows these patients nonsymptomatic progression of the disease from the results of the study, they are more willing to commit to treatment before their cardiac conditions worsen. Another obstacle to ordering CCTA, for referring physicians, is concern about the radiation exposure associated with the study. Dowe points out, however, that the test has “an ultralow radiation dose, at or less than what you get from a calcium study.” Fammartino believes that those who don't have a family history of coronary disease and are not having any symptomatic issues should probably wait for testing if they express concerns about radiation. A primary advantage of CCTA over other cardiac diagnostic tests is its ability to catch the disease process at an early stage, Feitelson says, expressing his frustration with false positives for nuclear studies and false negatives for stress tests, both of which are confusing to patients who end up with significant heart disease. In fact, he cites one patient who had a negative stress test and had blockages in three arteries. The CCTA confirmed the need for immediate treatment. Both physicians agreed that one advantage for primary care physicians using CCTA is that they are able to maintain and appropriately manage their own patients. While they will refer to specialists as needed, not all patients with chest pain need to see pulmonologists, gastroenterologists, and cardiologists, Dowe says. Fammartino’s opinion has changed, as it relates to where the cardiologist fits in the reading of CCTA examinations. “As skilled as many of the radiologist are in this test, from experience, I have seen a clear advantage with a cardiologist being involved with the primary read, ” he says. When there is partial occlusion or questionable findings, cardiologists, in partnership with radiologists, can provide a more comprehensive opinion to primary care providers, he adds. “It’s a great test, and I’d like to see more done,” Feitelson says. Fammartino also believes that CCTA could become an important part of the high-risk patient’s early screening, with a baseline study being conducted in the patient’s early or mid 40s. “Health care will advance to be more focused on preventive medicine than treating acute events,” Fammartino hopes. “CCTA can be a very useful tool, if done in conjunction with an overall focus on wellness and lifestyle choices.”