CCTA could make invasive angiography a thing of the past
Invasive diagnostic coronary angiograms have been the backbone of coronary artery disease (CAD) assessment for decades. However, many cardiology experts are predicting the rapid growth of coronary CT angiography (CCTA) will very soon eliminate the need for catheterizing patients just to shoot pictures. Thought leaders in cardiac CT have been discussing the potential of such a trend for years, and now CT hardware, software and artificial intelligence (AI) have all caught up enough that it truly seems possible. In fact, interventional cardiologists and cardiac surgeons have now joined cardiac imagers in support of CCTA.
"We still rely on invasive coronary angiography (ICA) to make the basic diagnosis of CAD, but we don't use black and white cameras anymore, or TV cameras that are as big as a microwave oven anymore. Technology has changed the way we image everything around us, except how we look at the coronary arteries. CCTA is changing that rapidly," explained John D. Puskas, MD, MSc, PhD, professor of surgery and chief of cardiothoracic surgery at Emory University Hospital Midtown.
He said CCTA technology, especially AI-driven advances in automation thanks to fractional flow reserve (FFR-CT) and soft plaque analysis, has given noninvasive CT diagnostic capabilities far beyond those of invasive angiography.
"The hardware and software are improving so quickly that diagnostically, ICA will be dead in a pretty short time, well within my practicing lifetime. We will only use invasive angiography to do percutaneous coronary intervention (PCI), but we will screen and make treatment decisions based on CCTA," Puskas explained.
CCTA was first widely used in cardiac assessments to help inform heart team decisions in structural heart cases more than a decade ago. The heart team concept involved shared decision making between interventional cardiologists, cardiac surgeons and cardiac imagers originally for decisions about patient selection for trancatheter aortic valve replacement (TAVR), but since has expanded to other facets of cardiac care.
Puskas said CCTA has proven its value for assessing structural heart cases and is now being rapidly adopted for coronary artery plaque assessment so heart teams can make better decisions about the use of coronary artery bypass grafts (CABG) and PCI.
AI enables objective decision making between surgeons and interventionists
Puskus said the heart team concept for shared decision making has not been adopted in all places. Some hospitals still have fierce competition between surgeons and interventionalists for patient volumes. He said decisions are not always being made based on the specific characteristics of each patient. However, he thinks the combination of AI and CCTA could help in this area.
Puskus also sees a future where the use of AI is mandated when, for example, it is time to determine if CAD patients require CABG or PCI. He said this might be especially helpful at centers that do not already use the heart team approach.
"The truth is, there is a tremendous variability in individual cities, and certainly between countries, with a dramatic difference in ratio between PCI and CABG. It is likely biology does not explain this variability. If we can drive toward more objective assessments that consider the coronary anatomy and the comorbidities of the patient, along with the patient's desires, we will do a better job providing appropriate care."
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]