- Email: [email protected]
Tipping point
Journal of Cardiovascular Computed Tomography (2012) 6, 218–219
From the Desk of the President
Tipping point Dear Colleagues: In the previous issues of the President’s Page, we focused on several of the active initiatives of the Society of Cardiovascular Computed Tomography (SCCT), having discussed the efforts of the SCCT to focus on increasing international growth of our membership, the integration of fellows and residents in training into a dedicated governance structure within the SCCT, and the SCCT’s realization of the ever-expanding indications of cardiovascular CT, coupled with formal application for dedicated Category III CPT codes for CT myocardial perfusion imaging. Pertaining to the latter, we appear to be at a ‘‘tipping point’’ for cardiovascular CT, particularly about its use in the emergency department (ED). Just recently in Chicago at the 2012 American College of Cardiology Scientific Sessions, Drs Harold Litt and Udo Hoffmann presented the exciting results of 2 late-breaking clinical trials; both of which significantly advance the scientific evidence base for the use of coronary CT angiography (CTA) in the ED. In the first of these, Dr Litt and colleagues performed a prospective multicenter randomized controlled trial of 1370 low-risk patients presenting to the ED with acute chest pain to determine the safety of coronary CTA as a diagnostic evaluation strategy compared with traditional ED care.1 The following results were observed: Safety of 100% (no death or myocardial infarction) was observed for the 640 patients with negative coronary CTAs at 30 days. Patients undergoing a coronary CTA-based strategy, compared with traditional care, experienced a .2-fold rate of direct discharge from the ED (49.6% vs 22.7%). Significantly shorter lengths of stay were observed for patients undergoing a coronary CTA-based strategy than a traditional care pathway (18.0 vs 24.8 hours; P , 0.001). Importantly, a higher frequency of diagnosis of coronary artery disease was observed for patients randomly assigned to the coronary CTA-based strategy than to traditional care (9.0% vs 3.5%).
In the second ROMICAT II trial, Dr Hoffmann and colleagues performed a prospective multicenter randomized controlled trial of 1000 patients presenting to the ED with .5 minutes of chest pain to determine whether a coronary CTA-based strategy could effectively reduce hospital length of stay.2 The following results were observed: Lengths of stay in the ED were significantly shorter in patients undergoing a coronary CTA-based strategy than a standard ED evaluation (23.2 vs 30.8 hours). An almost 3-fold higher rate of ED discharge within 12 hours was observed for patients undergoing a coronary CTA-based strategy than for standard ED evaluation, with almost two-thirds of patients in the coronary CTA arm undergoing rapid ED discharge (62% vs 21%). Direct ED discharge occurred almost 4 times as frequently for patients undergoing coronary CTA than for patients undergoing standard ED evaluation.
1934-5925/$ - see front matter Ó 2012 Society of Cardiovascular Computed Tomography. All rights reserved. doi:10.1016/j.jcct.2012.04.001
Min
President’s page
Time to diagnosis was almost 50% faster with a coronary CTA-based strategy than for standard ED evaluation. Congratulations to these investigators for their efforts! These 2 landmark randomized trials join the previously reported multicenter randomized CT-STAT trial to definitively establish the safety, effectiveness, and efficiency of coronary CTA use in the ED for patients presenting with chest pain.3 While continuing these imperative endeavors that establish the clinical foundation that allows us to foster the growth of coronary, cardiac, and cardiovascular CT, it bears consideration of one of the most vital reasons that our Society and we can do this. Since the introduction of 64detector row CT in 2005, we have seen the introduction of a minimum of 6 newer CT scanners, each with technical specifications that are better than the last. This represents the ‘‘flip side’’ of the proverbial research coin, balancing the clinical outcomes study with technology inquiries of the latest generation software and hardware. In this regard, the Journal of Cardiovascular Computed Tomography (JCCT) represents an ideal method to take in much of the important groundbreaking research in CT technologies that has direct effect on daily clinical coronary CTA evaluation of patients with suspected or known cardiovascular disease. This issue of the JCCT is no exception to this tradition, with numerous innovative CT advances reported. Notably, there are 2 original studies that report the incremental diagnostic performance of coronary CTA in patients who have historically been difficult to image accurately, namely, those with high heart rates and arrhythmias. These methods include a novel motion compensation algorithm that uses intracycle motion correction for improved diagnostic performance, as well as electrocardiographic gating as a method to reduce radiation dose during arrhythmias. Germane to the latter, we are also introduced to the concept of an automated method for dose-optimized selection of tube voltage as well as assessment of an iterative reconstruction algorithm to minimize radiation dose while maximizing image quality. Given the importance of image quality for accurate diagnoses, we see the differential effects of common artifacts on coronary CTA stenosis assessment versus FFRCT, or the
219 noninvasive calculation of fractional flow reserve from a typically acquired coronary CTA study. Finally, Dr Jorn Borgert introduces us to the future of cardiovascular CT by providing a treatise on the potential of magnetic particle imaging by CT. This bimodal approach to advancing the field of coronary CTA, namely by clinical outcomes evidence balanced by technology development, has been astonishingly rapid, and, in truth, sometimes it is difficult to keep pace. As I reflect on this, I think that it is probably the best problem to have. It is truly a dynamic field that we are all involved in, and I remain steadfast in my belief that the work that we are all doing together has proven and will continue to prove the immense clinical utility of coronary CTA. James K. Min, MD Departments of Medicine, Imaging and Biomedical Sciences Cedars-Sinai Heart Institute Cedars-Sinai Medical Center Los Angeles, CA 90048, USA E-mail address: [email protected]
References 1. Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW, Leaming JM, Gavin LJ, Pacella CB, Hollander JE: CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med. 2012;366:1393–403. 2. Hoffmann U, Truong Q, Lee H, Eric Chou, Woodard P, Nagurney J, Pope JH, Hauser T, White H, Weiner S, Goehler A, Zakroysky P, Kirby R, Hayden D, Wiviott S, Fleg J, Gazelle S, Schoenfeld D, Udelson J, Massachusetts General Hospital - Cardiac MR PET CT Program, Boston, MA, USA: Multicenter randomized comparative effectiveness trial of cardiac CT vs alternative triage strategies in acute chest pain patients in the emergency department: results from the ROMICAT II Trial (abstract of presentation 308-9). Presented at the 61st annual scientific session of the American College of Cardiology; March 27, 2012; Chicago, IL. 3. Goldstein JA, Chinnaiyan KM, Abidov A, Achenbach S, Berman DS, Hayes SW, Hoffmann U, Lesser JR, Mikati IA, O’Neil BJ, Shaw LJ, Shen MY, Valeti US, Raff GL, CT-STAT Investigators: The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial. J Am Coll Cardiol. 2011;58:1414–22.
From the Desk of the President
Tipping point Dear Colleagues: In the previous issues of the President’s Page, we focused on several of the active initiatives of the Society of Cardiovascular Computed Tomography (SCCT), having discussed the efforts of the SCCT to focus on increasing international growth of our membership, the integration of fellows and residents in training into a dedicated governance structure within the SCCT, and the SCCT’s realization of the ever-expanding indications of cardiovascular CT, coupled with formal application for dedicated Category III CPT codes for CT myocardial perfusion imaging. Pertaining to the latter, we appear to be at a ‘‘tipping point’’ for cardiovascular CT, particularly about its use in the emergency department (ED). Just recently in Chicago at the 2012 American College of Cardiology Scientific Sessions, Drs Harold Litt and Udo Hoffmann presented the exciting results of 2 late-breaking clinical trials; both of which significantly advance the scientific evidence base for the use of coronary CT angiography (CTA) in the ED. In the first of these, Dr Litt and colleagues performed a prospective multicenter randomized controlled trial of 1370 low-risk patients presenting to the ED with acute chest pain to determine the safety of coronary CTA as a diagnostic evaluation strategy compared with traditional ED care.1 The following results were observed: Safety of 100% (no death or myocardial infarction) was observed for the 640 patients with negative coronary CTAs at 30 days. Patients undergoing a coronary CTA-based strategy, compared with traditional care, experienced a .2-fold rate of direct discharge from the ED (49.6% vs 22.7%). Significantly shorter lengths of stay were observed for patients undergoing a coronary CTA-based strategy than a traditional care pathway (18.0 vs 24.8 hours; P , 0.001). Importantly, a higher frequency of diagnosis of coronary artery disease was observed for patients randomly assigned to the coronary CTA-based strategy than to traditional care (9.0% vs 3.5%).
In the second ROMICAT II trial, Dr Hoffmann and colleagues performed a prospective multicenter randomized controlled trial of 1000 patients presenting to the ED with .5 minutes of chest pain to determine whether a coronary CTA-based strategy could effectively reduce hospital length of stay.2 The following results were observed: Lengths of stay in the ED were significantly shorter in patients undergoing a coronary CTA-based strategy than a standard ED evaluation (23.2 vs 30.8 hours). An almost 3-fold higher rate of ED discharge within 12 hours was observed for patients undergoing a coronary CTA-based strategy than for standard ED evaluation, with almost two-thirds of patients in the coronary CTA arm undergoing rapid ED discharge (62% vs 21%). Direct ED discharge occurred almost 4 times as frequently for patients undergoing coronary CTA than for patients undergoing standard ED evaluation.
1934-5925/$ - see front matter Ó 2012 Society of Cardiovascular Computed Tomography. All rights reserved. doi:10.1016/j.jcct.2012.04.001
Min
President’s page
Time to diagnosis was almost 50% faster with a coronary CTA-based strategy than for standard ED evaluation. Congratulations to these investigators for their efforts! These 2 landmark randomized trials join the previously reported multicenter randomized CT-STAT trial to definitively establish the safety, effectiveness, and efficiency of coronary CTA use in the ED for patients presenting with chest pain.3 While continuing these imperative endeavors that establish the clinical foundation that allows us to foster the growth of coronary, cardiac, and cardiovascular CT, it bears consideration of one of the most vital reasons that our Society and we can do this. Since the introduction of 64detector row CT in 2005, we have seen the introduction of a minimum of 6 newer CT scanners, each with technical specifications that are better than the last. This represents the ‘‘flip side’’ of the proverbial research coin, balancing the clinical outcomes study with technology inquiries of the latest generation software and hardware. In this regard, the Journal of Cardiovascular Computed Tomography (JCCT) represents an ideal method to take in much of the important groundbreaking research in CT technologies that has direct effect on daily clinical coronary CTA evaluation of patients with suspected or known cardiovascular disease. This issue of the JCCT is no exception to this tradition, with numerous innovative CT advances reported. Notably, there are 2 original studies that report the incremental diagnostic performance of coronary CTA in patients who have historically been difficult to image accurately, namely, those with high heart rates and arrhythmias. These methods include a novel motion compensation algorithm that uses intracycle motion correction for improved diagnostic performance, as well as electrocardiographic gating as a method to reduce radiation dose during arrhythmias. Germane to the latter, we are also introduced to the concept of an automated method for dose-optimized selection of tube voltage as well as assessment of an iterative reconstruction algorithm to minimize radiation dose while maximizing image quality. Given the importance of image quality for accurate diagnoses, we see the differential effects of common artifacts on coronary CTA stenosis assessment versus FFRCT, or the
219 noninvasive calculation of fractional flow reserve from a typically acquired coronary CTA study. Finally, Dr Jorn Borgert introduces us to the future of cardiovascular CT by providing a treatise on the potential of magnetic particle imaging by CT. This bimodal approach to advancing the field of coronary CTA, namely by clinical outcomes evidence balanced by technology development, has been astonishingly rapid, and, in truth, sometimes it is difficult to keep pace. As I reflect on this, I think that it is probably the best problem to have. It is truly a dynamic field that we are all involved in, and I remain steadfast in my belief that the work that we are all doing together has proven and will continue to prove the immense clinical utility of coronary CTA. James K. Min, MD Departments of Medicine, Imaging and Biomedical Sciences Cedars-Sinai Heart Institute Cedars-Sinai Medical Center Los Angeles, CA 90048, USA E-mail address: [email protected]
References 1. Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW, Leaming JM, Gavin LJ, Pacella CB, Hollander JE: CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med. 2012;366:1393–403. 2. Hoffmann U, Truong Q, Lee H, Eric Chou, Woodard P, Nagurney J, Pope JH, Hauser T, White H, Weiner S, Goehler A, Zakroysky P, Kirby R, Hayden D, Wiviott S, Fleg J, Gazelle S, Schoenfeld D, Udelson J, Massachusetts General Hospital - Cardiac MR PET CT Program, Boston, MA, USA: Multicenter randomized comparative effectiveness trial of cardiac CT vs alternative triage strategies in acute chest pain patients in the emergency department: results from the ROMICAT II Trial (abstract of presentation 308-9). Presented at the 61st annual scientific session of the American College of Cardiology; March 27, 2012; Chicago, IL. 3. Goldstein JA, Chinnaiyan KM, Abidov A, Achenbach S, Berman DS, Hayes SW, Hoffmann U, Lesser JR, Mikati IA, O’Neil BJ, Shaw LJ, Shen MY, Valeti US, Raff GL, CT-STAT Investigators: The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial. J Am Coll Cardiol. 2011;58:1414–22.