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Please discuss.
Cardiac CT's Save Hospitals Money, But Do They Save Lives?
- Thread starter WilcoWorld
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Probably yes, but the "n" would have to be fairly high. We'd have to do cardiac CT on everyone with chest pain. That being said, it's not a test available at all facilities, as generally you need a 64-slice scanner and a radiologist trained to interpret the films.
No study is 100% sensitive at detecting CAD. A recent paper demonstrated that intravascular ultrasound at the time of cardiac angiogram picked up a large number of clinically significant blockages that regular angiogram missed.
D
deleted109597
No. The false positive rate is too high. The radiation dose is significant. You have to have someone without too many calcifications and who has an appropriate heart rate. It's a test of convenience only.
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I think if you risk-stratify before doing the test you could eliminate some of the false positives. I wouldn't say that the 40 year old with no medical problems and one episode of pain would benefit from a CT.
D
deleted109597
Even with risk stratifying, the test calls a 50% stenosis positive, and I argue that it isn't. We really don't have a great test for CAD that doesn't over treat the population, as evidenced by the intravascular ultrasound data. So we infer.
Plus, our radiologists here won't read them. Comically, the nighthawk guys will on occasion, when I order PE studies, comment on coronaries. The daytime overread always leaves that part out.
Plus, our radiologists here won't read them. Comically, the nighthawk guys will on occasion, when I order PE studies, comment on coronaries. The daytime overread always leaves that part out.
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My n=1 of experience...
The one I am aware of was told they had a 90% blockage in the LAD. They had a cath, and it was no where near the stenting range. I wonder if this is a common occurrence (false positive). More concerning would be the false neg rate, but the false positive puts them through a possibly unnecessary procedure (depending of course on risk factors and clinical appearance).
The one I am aware of was told they had a 90% blockage in the LAD. They had a cath, and it was no where near the stenting range. I wonder if this is a common occurrence (false positive). More concerning would be the false neg rate, but the false positive puts them through a possibly unnecessary procedure (depending of course on risk factors and clinical appearance).
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CCTA is not appropriate for routine use in the low-risk chest pain population unless we just want to do more tests as part of defensive medicine.
That worthless article in NEJM where they were trying to show CCTA negative folks had a <1% incidence of major cardiovascular events at 30 days...selected an entire 1,370 patient cohort that only had a 1% incidence of major cardiovascular event at 30 days (all nonfatal MIs). So, of course their test looked good at ruling out cardiac events - same as every other study of CCTA. Great when it's negative, still low yield when positive. It's the d-Dimer of low-risk chest pain imaging.
If you have an ED chest pain obs unit and you want to increase billing, shove everyone in there and run a CCTA. You'll decrease LOS and just consult all the positive or indeterminates to make them someone else's problem.
If you want to practice responsible medicine, send them all home after reasonable ED evaluation. Rather, move to Texas, and then do that - not all litigation environments will be so keen on a non-zero-miss practice.
I wrote about this a few days ago when it came out. Lots of conflict of interest issues, too:
EMLitofNote on CCTA
That worthless article in NEJM where they were trying to show CCTA negative folks had a <1% incidence of major cardiovascular events at 30 days...selected an entire 1,370 patient cohort that only had a 1% incidence of major cardiovascular event at 30 days (all nonfatal MIs). So, of course their test looked good at ruling out cardiac events - same as every other study of CCTA. Great when it's negative, still low yield when positive. It's the d-Dimer of low-risk chest pain imaging.
If you have an ED chest pain obs unit and you want to increase billing, shove everyone in there and run a CCTA. You'll decrease LOS and just consult all the positive or indeterminates to make them someone else's problem.
If you want to practice responsible medicine, send them all home after reasonable ED evaluation. Rather, move to Texas, and then do that - not all litigation environments will be so keen on a non-zero-miss practice.
I wrote about this a few days ago when it came out. Lots of conflict of interest issues, too:
EMLitofNote on CCTA
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Great points everyone, thanks. I especially like the ddimer analogy. I worry that, based on some garbage studies - showing low miss rate in a low risk population and a cost savings analysis that doesn't consider all of the costs - this might get pushed on some of us by governing bodies.
Good write-up, totally agree with your analysis.
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I believe you can significantly knock the radiation dose down if you eliminate calcium scoring...or so I've heard.
