Cardiovascular disease remains the leading cause of death worldwide for both men and women, taking the lives of over 17.9 million people each year. Recent studies demonstrate coronary computed tomography angiography (CCTA) is an effective first-line diagnostic tool for screening patients suspected of CAD.

In this blog post, we have compiled recent clinical trials summarizing the benefits of CCTA in clinical practice, as well as the current recommendations on using CCTA for screening patients with suspected CAD.

Evidence Supporting a Coronary CTA-first Strategy

Scottish Computed Tomography of the Heart (SCOT-HEART) Trial

Researchers at the University of Edinburgh in Scotland conducted the Scottish Computed Tomography of the Heart (SCOT-HEART) Trial to assess the effectiveness of CCTA in the diagnosis, management, and outcomes of patients with suspected CAD. In the prospective, multicenter trial, patients were randomly assigned to two groups: standard of care alone, or standard of care in addition to calcium score and CCTA. The study results demonstrated that CCTA can lead to the more appropriate use of invasive angiography and care management changes, supporting evidence that CCTA can improve clinical decision-making and patient outcomes [1]

In a follow-up study of the SCOT-HEART trial published in The New England Journal of Medicine, researchers examined the five-year outcomes of 4,146 patients who presented with stable chest pain. The study results showed that CCTA in addition to standard of care was associated with a 41% lower risk of nonfatal myocardial infarction (MI) or death from CAD than standard of care alone [2]

Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) 

The Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) has demonstrated additional benefits related to the usage of CCTA. The initial study findings published in the New England Journal of Medicine in 2015 concluded that an initial strategy of CCTA compared to functional testing did not improve clinical outcomes over a median follow-up of 2 years (3). However, secondary analyses of the PROMISE trial have revealed improvements in accuracy, safety, and preventative medication with the usage of CCTA.

In the research paper “Prognostic Value of Noninvasive Cardiovascular Testing in Patients With Stable Chest Pain” published in Circulation, researchers concluded that CCTA can provide better prognostic information than functional testing in patients who have stable chest pain with a low burden of obstructive CAD, myocardial ischemia, and events [4].

International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA)

The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) aimed to evaluate routine invasive therapy when compared to optimal medical therapy among patients with stable ischemic heart disease and moderate to severe myocardial ischemia on noninvasive stress testing. Insights from the ISCHEMIA trial published in The New England Journal of Medicine demonstrated that an initial invasive strategy compared with an initial conservative strategy did not reduce the risk of ischemic cardiovascular events or death [5].

According to the results of the ISCHEMIA trial, an initial conservative strategy was equally as effective as an initial invasive strategy in guiding the treatment of patients with stable coronary disease and moderate or severe ischemia. The NHLBI-funded study aimed to determine the best way to manage patients with stable ischemic heart disease.

Randomized Evaluation of Patients with Stable Angina Comparing Utilization of Noninvasive Examinations (RESCUE) Trial

Consistent with the results from the ISCHEMIA study, the results from the Randomized Evaluation of Patients with Stable Angina Comparing Utilization of Noninvasive Examinations (RESCUE) Trial demonstrates that CCTA is an effective alternative to SPECT for evaluating patients with stable angina. The randomized, controlled, multi-center clinical trial compared CCTA and SPECT-MPI for assisting in the diagnosis of ischemic heart disease in patients with stable angina. In the trial, there were no differences in outcomes between patients who underwent CCTA in comparison with SPECT. The study revealed that CCTA was a better predictor of major adverse cardiac events (MACE) and revascularization.

Recommendations & Guidelines for the Use of CCTA

As evidence builds in support of a CCTA-first strategy, cardiovascular associations have released new guidelines recommending the usage of CCTA for diagnosing CAD in clinical practice.

National Institute For Health and Care Excellence (NICE) Guidance 

The United Kingdom has paved the way for the use of CCTA in clinical practice for the management of patients with CAD. In November 2016, the National Institute for Health and Care Excellence (NICE) published the “NICE Guidance for Stable Chest Pain Patients to Appropriately Diagnose Patients with Suspected Coronary Artery Disease.” According to guideline CG95, CCTA should be offered if clinical assessment indicates typical or atypical angina or clinical assessment has indicated non-anginal chest pain but 12-lead resting ECG has been done and indicates ST-T changes or Q waves. The guidelines also recommend CCTA as the first-line investigation for all patients with angina and no prior CAD.

European Society of Cardiology (ESC) Guidelines

Building on evidence from the SCOT-HEART Trial and the PROMISE Trial, the European Society of Cardiology published updated guidelines on the diagnosis and management of chronic coronary syndromes in September 2019. The updated guidelines state that CCTA should be used for diagnosing CAD in symptomatic patients in whom obstructive CAD cannot be excluded by clinical assessment alone.

American College of Cardiology (ACC) Recommendations

The American College of Cardiology (ACC) published new recommendations for the usage of CCTA in September 2020 in the Journal of the American College of Cardiology. The report titled, “Current Evidence and Recommendations for Coronary CTA First in Evaluation of Stable CAD,” synthesize evidence from the SCOT-HEART, PROMISE, and ISCHEMIA trials in support of the use of CCTA. In the report, the authors state that CCTA should be used as a first-line diagnostic tool in patients with stable chest pain with possible obstructive CAD.

Society of Cardiovascular Computed Tomography (SCCT) 2021 Expert Consensus on CCTA

The Society of Cardiovascular Computed Tomography (SCCT), released a new expert consensus document updating previous recommendations for the use of CCTA on February 9. The document titled “SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography” was published in the Journal of Cardiovascular Computed Tomography.

With evidence growing in support of CCTA, the consensus statement includes the following recommendations for CCTA in the evaluation of stable CAD:

  • Evaluation of Stable CAD: CCTA in Native Vessels
  • Evaluation of Stable CAD: CCTA Post-revascularization
  • Evaluation of Stable CAD: CCTA with FFR or CTP
  • Evaluation of Stable CAD: CCTA in Other Conditions
  • Reporting on CTA: Coronary and Non-coronary Information

Improving the Adoption and Utilization of CCTA

As evidence continues to build in support of a CCTA-first strategy, we can all help contribute to accelerating progress. To help support the adoption and utilization of CCTA, consider taking the following steps:

  • Improve education on CCTA in clinical practice. Associations including the Society of Cardiovascular Computed Tomography have created resources to help educate providers on CCTA. Review the educational materials online and share them with colleagues.
  • Help address the challenges of CCTA reimbursement. CMS underestimates the costs for CCTA which impacts the rate at which it is reimbursed in the United States. Contribute to improving reimbursement for CCTA by ensuring standardization in reporting and advocating for improved reimbursement.
References

[1] Williams MC, Hunter A, Shah ASV, Assi V, Lewis S, Smith J, Berry C, Boon NA, Clark E, Flather M, Forbes J, McLean S, Roditi G, van Beek EJR, Timmis AD, Newby DE; SCOT-HEART Investigators. Use of Coronary Computed Tomographic Angiography to Guide Management of Patients With Coronary Disease. J Am Coll Cardiol. 2016 Apr 19;67(15):1759-1768. doi: 10.1016/j.jacc.2016.02.026. PMID: 27081014; PMCID: PMC4829708.

[2] The SCOT-HEART Investigators. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. N Engl J Med 2018;379:924-33.

[3] Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372(14):1291-1300. doi:10.1056/NEJMoa1415516

[4] Hoffmann U, Ferencik M, Udelson JE, Picard MH, Truong QA, Patel MR, Huang M, Pencina M, Mark DB, Heitner JF, Fordyce CB, Pellikka PA, Tardif JC, Budoff M, Nahhas G, Chow B, Kosinski AS, Lee KL, Douglas PS; PROMISE Investigators. Circulation. 2017 Apr 7;135:2320-2332. doi: https://doi.org/10.1161/CIRCULATIONAHA.116.024360

[5] Maron DJ, Hochman JS, Reynolds HR, Bangalore S, O’brien SM, Boden WE, Chaitman BR, Senior R, Lopez-Sendon J, Alexander KP, Lopes RD, Shaw LJ, et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020 Apr 9; 382:1395-1407. doi:10.1056/NEJMoa1915922